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CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)
Left Main Coronary Artery Thrombus Treated By Drug Eluting Stent.
Ahmed Shaheen1
Louran, Egypt1,
[Clinical Information]
- Patient initials or identifier number:
-Relevant clinical history and physical exam:
75y old male known to be diabetic(type2),  hypertensive, Heavy smoker and    dyslipidemic .Presented by typical chest pain  associated with   sweeting , and excessive vomiting for 3 hours. In emergency department , patient crushed and his blood pressure  became unrecorded.He was  promptly   transferred         to intensive care unit on maximum vasopressors dose. His blood pressure was still unrecorded ,however. Patient ,then has been intubated and kept on       mechanical ventilation .

-Relevant test results prior to catheterization:
His electrocardiogram showed ST elevation in lead I ,AVL , V2-V6 with right bundle branch block and  Bed side Echo showed sever anterior, anterolateral ,  apical and septal  hypokinesis and Ejection fraction was 10-15% .His Troponin was positive but  all other labs were normal .   

- Relevant catheterization findings:
Coronary angiography through trans-femoral  approach showed ; 100% left main thrombus occluded lesion .

[Interventional Management]
- Procedural step:
In emergency department; patient  arrested  in ventricular fibrillation immediate cardiopulmonary resuscitation   was started, thankfully, patient restored his circulation  after 4 cycles .Intensive care unit  activated cathlab around 3.00 am . In cathlab :Xtra backup  3.5 mm Guiding catheter was engaged into left main coronary artery ,then workhorse  0.0014 wire was secured distally in to ramus  intermedius artery.  Pre dilatation  using  2.00 /15 mm compliant  balloon and inflated at   10 atm and  Then  wiring both left anterior descending artery and left circumflex artery using two  0.0014 workhorse wires was done  .Drug eluting stent 3.00/ 28 mm was deployed from the left main ostium down t to proximal left anterior descending artery at 16 atm , Finally  Proximal optimisation using  3.5 / 15 mm noncompliant  balloon was done at 20 atm with good final result .
- Case Summary:
ST-elevation myocardial infarction (STEMI) involving the left main coronary artery (LMCA) has been associated with significant morbidity and mortality. Most studies are limited by small sample sizes.PCI of the ULMCA should be considered as a viable alternative to CABG for selected patients with MI, including those with ULMCA occlusion and less than Thrombolysis In Myocardial Infarction flow grade 3, cardiogenic shock, persistent ventricular arrhythmias, and significant comorbidities. The higher risk of target vessel revascularization associated with ULMCA PCI compared with CABG is acceptable given the primary need for rapid reperfusion to enhance survival.
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