CASE 41 Postoperative Acute STEMI

Case presentation

A 69-year-old man with a history of coronary artery disease presented for a left nephroureterectomy for transitional cell carcinoma. Two years prior to presentation, he underwent percutaneous coronary intervention with placement of a 3.0 mm diameter by 18 mm long sirolimus-eluting stent in the proximal circumflex and a 2.5 mm diameter by 18 mm long sirolimus-eluting stent in the mid-left anterior descending artery. He was treated for 6 months with dual antiplatelet therapy consisting of aspirin and clopidogrel, after which he was continued on low-dose aspirin. Aspirin was discontinued 3 weeks prior to surgery. The nephroureterectomy was performed laparoscopically under general anesthesia and the patient tolerated the procedure with no complications. Following transfer to the postanesthesia care unit, the patient developed marked ST depressions in leads V2 through V5, followed by ventricular fibrillation requiring multiple defibrillations with subsequent intubation. One dose of amiodarone was given and a lidocaine drip was started. After consultation with the surgeons, a heparin bolus was given and he was transferred to the cardiac catheterization laboratory for emergent angiography.

Cardiac catheterization

The right coronary artery was small and nondominant, with luminal irregularities (Figure 41-1). The left anterior descending artery (LAD) was patent with a long tubular stenosis of mild severity just prior to the previously placed stent. The stent itself was widely patent. The circumflex artery was occluded at the ostium within the previously placed stent, consistent with late stent thrombosis (Figure 41-2 and Video 41-1). Anticoagulation was achieved with heparin and abciximab, and a 0.014 inch guidewire was advanced easily through the thrombosed stent and into the distal circumflex. The lesion was dilated with a 3.0 mm diameter by 15 mm long compliant balloon with return of flow to the artery, but with residual thrombus (Figure 41-3 and Video 41-2). The operator felt there was residual stenosis and attempted to dilate the lesion with a 3.0 mm diameter by 15 mm long noncompliant balloon. However, the balloon would not advance into the stented segment. A 2.5 mm diameter by 15 mm long noncompliant balloon was advanced easily into the lesion and inflated to high pressure. Subsequently, the 3.0 mm diameter noncompliant balloon passed easily and the lesion was dilated multiple times with high-pressure inflations. The final angiogram revealed minimal thrombus within the stented segment and the artery had TIMI-3 flow (Figure 41-4 and Video 41-3).