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CASE20191027_007
| CORONARY - Complications | |
| A Successful Bail-Out Case from Sudden Onset of No Flow Phenomenon with Undiagnosed Origin in Whole Left Coronary Artery | |
| Tetsuya Nomura1 | |
| Kyoto Chubu Medical Center, Japan1, | |
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[Clinical Information]
- Patient initials or identifier number:
T.M.
-Relevant clinical history and physical exam:
An 88-year-old Japanese female with type 2diabetes mellitus and polymyalgia rheumatica complained of a worsening exertional chest discomfort. Her blood pressure was 157/70mmHg, and pulse was 94/minwith a regular rhythm. No pathological heart murmur was audible and respiratorysound was clear.
-Relevant test results prior to catheterization:
Laboratory examinations showed no remarkable finding. An electrocardiogramdemonstrated sinus rhythm, poor progression of R-wave in anterior chest leads, anda slightly depressed ST-segment in I, aVL, V5~6 leads. An echocardiogram showedfavorable left ventricular contractility and no significant valvulardysfunction. Neither abnormal shunt flow nor pooling of epicardial effusion wasvisualized.
- Relevant catheterization findings:
Coronary angiography (CAG) showed moderate stenosis inproximal segment of the right coronary artery and tandem lesions withsignificant stenoses in the left anterior descending (LAD) artery.
 pre CRA.mpg |
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[Interventional Management]
- Procedural step:
We startedpercutaneous coronary intervention (PCI) for the LAD artery. A 6Fr Hyperion SPB3.5 guide catheter was alittle bit deeply engaged toward left circumflex (LCX) artery, we passed aninitial guidewire to the high lateral branch, and a second guidewire to the LADartery. At that time, the patient suddenly complained of chest pain, and wechecked CAG. Unexpectedly, coronary blood flow appeared in neither LAD nor LCXarteries. Meanwhile, her hemodynamics drastically collapsed and then soonresulted in cardiac arrest. Immediately, performing chest compression, weestablished a veno-arterial extracorporeal membrane oxygenation (VA-ECMO)system for stabilization of the hemodynamics as soon as possible. Under theVA-ECMO support, CAG showed coronary blood flow, which recovered similarly tothat seen on the initial angiography in the left coronary artery. Optical coherence tomography showed neitherfinding of coronary dissection nor ruptured plaque from LAD artery to left maintrunk. Her hemodynamics got stable, then we resumed PCI and deployed twodrug-eluting stents, resulting in a favorable blood flow. After PCI, she waspromptly weaned off VA-ECMO and discharged on foot 9 days after PCI without anyneurological sequelae.
No flow CRA.mpg No flow CAU.mpg post CRA.mpg- Case Summary:
There are several supposed causes of sudden coronary flow disturbance thatpossibly happens during PCI, such as coronary dissection, distal embolism,vasospasm, and reduced driving pressure in coronary arteries. However, we couldnot detect any evidences which suggested those causes of sudden coronary flowdisturbance in our case. Therefore, we would like to discuss about the supposedcauses of this pathological entity in our case.
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