Intravascular Ultrasound to Identify Culprit Lesions in Non-ST Segment Elevation Myocardial Infarction
Presenter
Judit Karacsonyi, MD, PhD, Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN
Judit Karacsonyi, MD, PhD, Spyridon Kostantinis, MD, Bahadir Simsek, MD and Emmanouil S. Brilakis, MD, PhD, FSCAI, Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN
Title:
Intravascular Ultrasound to Identify Culprit Lesion in Non-ST Segment Elevation Myocardial Infarction
Introduction:
A 60-year-old woman with NSTEMI and ongoing chest pain was referred for coronary angiography to our center. She had a history of Type 2 diabetes mellitus, stage III chronic kidney disease, hypertension, rheumatoid arthritis, osteoporosis and obesity.
Clinical Case:
Troponin levels were increasing 0.721 → 0.831 → 4.135. The electrocardiogram demonstrated atrial fibrillation and ST depression in the anterolateral leads.
No significant lesion was found on the angiography on either major coronary vessels. A diagonal side branch was filling late, but the origin of the vessel was not visible. A workhorse wire was inserted to the left anterior descending coronary artery (LAD) and intravascular ultrasound (IVUS) was performed to visualize the origin of the occluded diagonal vessel. IVUS revealed the LAD-diagonal bifurcation and wiring was attempted first with a Samurai wire, which was unsuccessful. Finally, after multiple attempts, the IVUS guided Sion Black guidewire crossed the occlusion and opened up the vessel. IVUS confirmed true lumen crossing and predilation was performed reestablishing the antegrade flow in the vessel. A 3.5x15 mm drug eluting stent (DES) was deployed in the ostium of the diagonal branch after careful positioning from multiple angles. Final IVUS revealed well expanded stents and the final angiography revealed TIMI 3 flow with no compromised flow in the LAD. Discussion:
F
lush side branch ostial occlusions can be challenging to detect, especially in an acute setting. IVUS can identify location of occluded side branch and confirm guidewire position.