Car Crash to Cath Lab: The Unexpected ST Elevations
Presenter
Shruti Singh, MD, The University of Texas Health Science Center at Houston, Houston, TX
Shruti Singh, MD1, Husam Shadid, MD1, Muhammad T Bajwa, MD2, Hassan Ashraf, MD1 and Salman A. Arain, MD, FSCAI3, (1)The University of Texas Health Science Center at Houston, Houston, TX, (2)UTHealth-McGovern Medical School, Sugar Land, TX, (3)UTHealth-McGovern Medical School, Houston, TX
Title
Car Crash to Cath Lab: The Unexpected ST Elevations
Introduction
Coronary artery dissection resulting from blunt trauma to the chest is a rare occurrence. Furthermore, the underlying dissection might precipitate vasospasm or thrombus formation leading to acute myocardial infarction. The left anterior descending artery is more commonly affected when compared to the right. Here we present a case of right coronary artery dissection in a young patient after sustaining trauma to the chest, which led to thrombus formation in the right coronary artery (RCA) leading to a ST elevation myocardial infarction.
Clinical Case
Patient is a 20-year-old man who presented as a level 1 trauma after a motor vehicle accident. He was hypotensive to 82/52 on presentation, which improved with fluids. His initial EKG was noted to have ST elevations in the inferior leads and reciprocal ST depressions in Lead I. Code STEMI was activated and patient was emergently taken to the Cath lab. Coronary angiography revealed a filling defect in the mid to distal RCA consistent with thrombus. Patient underwent aspiration thrombectomy with improvement in ST segment elevations and thrombus burden. There was still as residual ostial RCA thrombus at the end of the case with possible underlying dissection. Intravascular ultrasound imaging was performed which confirmed the presence of traumatic dissection with ulceration and intraluminal thrombus. Given need for further interventions by trauma surgery team, unclear tolerance of dual antiplatelet therapy and otherwise patent RCA with TIMI-3 flow to distal branches, the procedure was stopped. He was subsequently found to have right humerus fracture which was reduced, grade 3 liver laceration, multiple rib fractures, spinous process fractures, and a left middle frontal gyrus hygroma. Repeat Angiography and optical coherence tomography imaging after 72 hours revealed improvement in thrombus burden and a small underlying dissection. Patient was discharged home on aspirin and Eliquis.
Discussion
Despite being a rare phenomenon following chest trauma, coronary artery dissection and thrombus formation can lead to increased morbidity and mortality. It can be a challenging diagnosis to make based on symptoms given chest trauma can result in multifactorial causes of chest pain. Therefore, the Eastern Association for Surgery of Trauma guidelines recommend initial electrocardiogram on any patient with suspected blunt chest trauma. No consensus guidelines regarding treatment exist for traumatic coronary artery dissection and thrombus formation. Thrombolysis should generally be avoided due to possible extension of underlying dissection and frequent co-existence of other injuries that could result in bleeding. Percutaneous coronary intervention with aspiration thrombectomy appears to be the mainstay of treatment in cases with thrombus formation. Stent placement should be considered based on the size of dissection and presence of other injuries. In our patient, the RCA dissection was small and did not require stent placement. The use of intravascular imaging and optical coherence tomography in evaluation of the size of dissection and underlying mechanism of myocardial infarction was important in the decision making for treatment.