Intravascular ultrasound-guided dissection recanalization in a patient with ST-segment elevation myocardial infarction: a case report

Abstract

Background

In primary percutaneous coronary intervention (PCI) for acute myocardial infarction, we occasionally experience challenging cases where conventional guidewires cannot pass through the lesion. In such cases, if the use of a tapered guidewire or polymer jacket guidewire is also unsuccessful, coronary artery bypass surgery becomes inevitable. Therefore, other methods to enable revascularization in a reliable and timely manner are desirable.

Case summary

We present the first case of intravenous ultrasound (IVUS)-guided tip detection (TD)-antegrade dissection re-entry (ADR) in a 73-year-old man who suffered ST-segment elevation myocardial infarction (STEMI). The patient had a total thrombotic occlusion of the right coronary artery and stenotic lesion of the left anterior descending artery. Primary PCI was unsuccessful and IVUS-guided rewiring using a chronic total occlusion (CTO) wire failed due to thrombus attenuation. However, IVUS imaging revealed the presence of intimal and subintimal space, which led us to perform IVUS-guided TD-ADR using Conquest Pro 12 ST (Asahi Intecc). Using the TD method, we were successful in swiftly puncturing the true lumen wall, and a stent was implanted following successful re-entry. Final angiography showed the establishment of Thrombolysis in Myocardial Infraction-3 flow and resolution of ST-segment elevation.

Discussion

IVUS-guided TD enables accurate puncture in an ADR procedure, enabling successful recanalization in a relatively short time. Thus, IVUS-guided TD-ADR is a reliable option for revascularization in STEMI cases wherein the guidewire fails to pass the occlusion using conventional techniques.

Learning points.

• In primary percutaneous coronary intervention for ST-segment elevation myocardial infraction, we occasionally experience challenging cases where conventional guidewires cannot pass through the lesion.

• Intravenous ultrasound-guided tip detection and antegrade dissection re-entry is a reliable option for ST-segment elevation myocardial infarction cases where the guidewire fails to pass through the occlusion site using conventional techniques, as in chronic total occlusion cases.

Introduction

Primary percutaneous coronary intervention (PCI) has improved acute myocardial infarction (AMI) mortality and morbidity.¹ In primary PCI procedures, crossing a guidewire beyond the occlusion site is the first step for successful revascularization; in most cases, this is not difficult, compared with chronic total occlusion (CTO) PCI cases.²

However, even in primary PCI, we occasionally encounter challenging cases where conventional guidewires cannot pass through the lesion. Failure to cross the guidewire past the culprit AMI lesion prevents successful revascularization via primary PCI. This can lead to serious complications, including heart failure, pump failure, arrythmia, and other mechanical complications, ultimately resulting in poor clinical outcomes.³

Timeline

Day 0	0 min	The patient was admitted to our hospital with complaints of chest pain. Electrocardiogram showed ST elevation in the inferior lead.
	30 min	Primary percutaneous coronary intervention (PCI) was performed; however, a conventional guidewire could not pass through the occlusion. Exchange of guidewires to a polymer jacketed guidewire Exchange of the guiding catheter
	90 min	Haemodynamic deterioration had occurred. Intra-aortic balloon pump insertion Intravenous temporary pacemaker was inserted through the right internal jugular vein
	110 min	Guidewire escalation and intravenous ultrasound (IVUS)-guided re-wiring had failed.
	160 min	IVUS-guided tip detection (TD)-antegrade dissection re-entry (ADR) was attempted as a last resort.
	180 min	Successful revascularization by IVUS-guided TD-ADR was confirmed.
Day 14		PCI was performed for a stenotic lesion of the left anterior descending artery.
Day 15		The patient was discharged.
6 months		Outpatient follow-up revealed no symptoms of heart failure or complaints related to the chest.

Case summary

A 73-year-old Asian man was admitted for ST-segment elevation myocardial infarction (STEMI). He had a history of hypertension and dyslipidaemia with no prior chronic medication treatment. He presented with chest pain with an onset 2 h prior to hospital arrival. In the emergency room, blood pressure was 124/80 mmHg, pulse was 72/min, lung fields were clear, heart sounds were normal. Electrocardiography showed ST-segment elevation in the inferior leads. Echocardiography on arrival at the hospital showed reginal wall motion abnormality in the infero-posterior wall (ejection fraction: 47%) with no apparent valvular disease. Laboratory tests at presentation showed non-elevated creatinine kinase (CK) (57 U/L, normal = 50–210 U/L) and CK-MB levels (12 U/L, normal = 0–25 U/L), but high-sensitivity troponin T was mildly elevated (0.032 ng/mL, normal = 0–0.016 ng/mL). Emergency coronary angiography revealed total thrombotic occlusion of the right coronary artery (RCA) and a stenotic lesion of the left anterior descending artery (LAD) with a septal collateral channel from the LAD to the RCA (Figure 1A–C; Supplementary material online, Videos S1 and S2). After taking prasugrel (20 mg) and aspirin (200 mg), the radial artery was not palpable, and primary PCI was performed through the right femoral artery using a 7-French JR40SH catheter. Although conventional guidewires were exchanged for a polymer-jacketed guidewire [SION blue (Asahi Intecc, Seto, Japan) → SION black (Asahi Intecc) → XTR (Asahi Intecc) with Zizai microcatheter (Terumo, Tokyo, Japan)] and guiding catheter (JR → IM → AL) for better back-up support, we were unable to pass a guidewire past the occlusion site. During PCI, an intra-aortic balloon pump (IABP) and temporary pacing were inserted due to hypotension and sinus bradycardia. The ST-segment elevation remained unresolved, and RCA revascularization was necessary. A retrograde approach required PCI for the LAD and was deemed a high-risk treatment option; hence, the wire was passed using an antegrade approach. As conventional guidewires and polymer-jacketed guidewires could not advance beyond the occluded site, we used a CTO wire (Miracle Neo3; Asahi Intecc) with an intermediate tip load (3 g) and Corsair microcatheter (Asahi Intecc) with the 7-Fr AL1 guiding catheter. The AnteOwl intravascular ultrasound (Terumo) revealed that the Neo3 wire had advanced to the subintimal space. The attempted intravascular ultrasound (IVUS)-guided rewiring failed because the transition point from the intima to subintimal space was not visible due to thrombus attenuation (Figure 2A). IVUS imaging showed intimal and subintimal space at the distal site of the occluded lesion (Figure 2B). Consequently, we performed IVUS-guided tip detection (TD)-antegrade dissection re-entry (ADR) using Conquest Pro 12 ST (Asahi Intecc, Japan), which was provided by Dr Tsuchikane, and a Corsair microcatheter. We were then able to accurately guide the wire to swiftly puncture the true lumen’s wall with the tip detection method (Figure 3B). The IVUS imaging confirmed the wire re-entry (Figure 3B; Supplementary material online, Videos S3 and S4). After successful re-entry, 3.0 × 38 mm and 3.5 × 24 mm drug-eluting stents were implanted. The final angiography results showed thrombolysis in myocardial infarction-3 flow (Figure 4A). Stent expansion and apposition were confirmed by IVUS imaging (Figure 4B) and resolved ST-segment elevation (Figure 4C). The door-to-balloon and procedure times were 180 and 240 min, respectively. The fluoroscopy time was 139 min, and the contrast volume was 205 mL. CK and CK-MB levels peaked at 3404 and 450 IU/L, respectively, 10 h after admission. Echocardiography performed the day after PCI showed reginal wall motion abnormality in the infero-posterior wall (ejection fraction: 47%). After PCI, the patient presented with heart failure, which was relieved by medical therapy. Staged PCI for LAD was performed on the 14th day. At that time, favourable blood flow in the RCA was confirmed. After PCI of LAD, the patient was discharged on day 15. At 6 months post-discharge, no symptoms of heart failure or chest-related complaints were reported.

Figure 1.

Coronary angiography imaging (A, B, C) and electrocardiogram (D).

Figure 2.

Intravenous ultrasound imaging in the right coronary artery with signal attenuation by the thrombus at the occluded site (A) and intima and subintimal space at the distal site of the occluded lesion (B).

Figure 3.

Angiographic imaging of intravenous ultrasound (IVUS)-guided tip detection-antegrade dissection re-entry (A) and IVUS imaging of guidewire tip direction (B).

Figure 4.

Final angiography demonstrating successful revascularization (A). Stent expansion and apposition are confirmed by intravenous ultrasound imaging (B). Electrocardiogram showing resolution of ST-segment elevation (C).

Discussion

This was a case of acute myocardial infarction with RCA occlusion. Conventional guidewires could not pass the occlusion site. Ultimately, successful revascularization was achieved using a newly reported CTO PCI wire-crossing technique, IVUS-guided TD-ADR.

Approximately 7% of AMI lesions required a polymer jacket-type or stiff guidewire to cross the culprit lesion.⁴ Herein, there was a septal collateral channel from the LAD to the RCA, and post-revascularization electrocardiogram showed pathological Q-waves in the inferior lead. This implied that severe stenosis happened before complete occlusion occurred at AMI onset. Antithrombotic therapies were treatment options; unfortunately, GIIb/IIIa inhibitors are unavailable in Japan.

The IVUS-guided PCI also improves long-term outcomes without increasing procedural complications by identifying myocardial infarction pathology, post-stenting dilation, tissue protrusion, residual thrombus, and stent edge problems.⁵ Okamura et al. reported the efficacy of IVUS-guided TD-ADR in CTO PCI.^6,7 Here, we present the first use of IVUS-guided TD-ADR in AMI. In CTO cases, target visualization by contralateral injection is very important. This is especially important for safe and reliable procedures when performing wire escalation and ADR using Stingray. In this case of myocardial infarction, target visualization by contrast injection was impossible, even though the collateral blood flow from the LAD to the RCA was recognized. Since the patient was haemodynamically unstable, performing ADR as proximally as possible was important to avoid the loss of the right ventricle (RV) branch. Through IVUS imaging, the distance between the thrombus-attenuated lesion (Figure 2A) and calcified lesion (Figure 2B) was identified as short. Proximal-site ADR could not be attempted, as the optimal re-entry point was limited (Figure 5). However, IVUS-guided TD-ADR allowed us to pinpoint the puncture by following the IVUS image, resulting in successful recanalization in a relatively short time without losing the RV branch. In this procedure, it is important to control a wire with high penetrating force under IVUS guidance. We were also concerned that even if the RCA had CTO and LAD stenosis was the culprit lesion, PCI of the LAD with diffuse stenosis in the setting of haemodynamic instability could lead to further haemodynamic deterioration. The IVUS-guided TD-ADR was the last resort for antegrade passage of the wire through the RCA occlusion. Coronary artery bypass grafting was inevitable with unsuccessful PCI.

Figure 5.

On intravenous ultrasound (IVUS) imaging, the optimal re-entry between the thrombus-attenuated and calcified lesions (black two-headed arrow) is short. Although the optimal re-entry point is limited, IVUS-guided tip detection-antegrade dissection re-entry could control the re-entry point without visualization of the target, resulting in successful recanalization without losing the RV branch. CP, Conquest Pro; Neo3, Miracle Neo3; RV branch, right ventricular branch.

Recently, the efficacy of IABP in AMI with shock has been questioned, and guidelines recommend against its routine use.⁸ However, in this case, haemodynamic stability was achieved with IABP, allowing PCI to safely continue and ultimately leading to successful revascularization.

The following points should be noted when performing IVUS-guided TD-ADR in AMI. Unlike CTO, the distal portion of the occlusion in ACS likely has poor collateral blood flow; branches lost by ADR in ACS cannot be expected to supply the collateral blood vessels. Therefore, re-entry must be performed closer to the occlusion. The IVUS-guided TD-ADR is an option in AMI cases wherein achieving wire access using conventional techniques is not possible. Coronary artery bypass grafting should be selected if the patient’s background is suitable. However, in the presence of ST-segment elevation, the time to reperfusion is critical, increasing the need for IVUS-guided TD-ADR.

Conclusion

The IVUS-guided TD-ADR may be a useful option in STEMI if the guidewire cannot pass the lesion with conventional techniques.

Lead author biography

Hideto Sangen was born in 1981, spent his childhood in Hong Kong, and later grew up in Tokyo, and graduated from Nippon Medical School in 2007. He trained cardiology at Nippon Medical School Hospital, Shizuoka Medical Center, and Hakuzikai Memorial General Hospital. He is currently working at Hakuzikai Memorial General Hospital as Chief of Cardiology. He specializes in cardiovascular emergency medicine and catheter intervention.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports.

Data availability

The data underlying this article are available in the article and in its online supplementary material.