Abstract
Achieving a door-to-balloon time <90 min may be challenging in patients with ST-segment elevation acute myocardial infarction with difficult to wire coronary lesions. We report use of the Venture wire control catheter to facilitate wiring in four patients with significant tortuosity proximal to a thrombotic coronary occlusion, after conventional wiring attempts failed. Early use of the Venture catheter may help shorten the door-to-balloon time in patients with challenging to wire lesions.
Shortening the door-to-balloon time in patients with ST-segment elevation acute myocardial infarction (STEMI) is critical for minimizing morbidity and mortality. While prompt STEMI recognition and activation of the catheterization laboratory is crucial, difficulty to wire the target lesion may cause delay in reperfusion. We report four STEMI cases, in which use of the Venture wire control catheter (St. Jude, Minneapolis, MN, USA) facilitated wiring of the culprit lesion and shortened the door-to-balloon time.
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Case 1
A 57-year-old man presented with posterior myocardial infarction ( Fig. 1 A ). Emergency coronary angiography performed with a 6-French 3.5 XB guiding catheter demonstrated thrombotic occlusion of the proximal circumflex artery ( Fig. 1 B). Wiring the proximal circumflex was challenging due to severe proximal angulation causing the wire to prolapse into the left anterior descending artery (LAD) ( Fig. 1 C). We were unable to advance an Asahi soft (Abbott Vascular, Santa Clara, CA, USA) or a Runthrough wire (Terumo, Somerset, NJ, USA) wire though the lesion, in spite of advancing them through an over-the-wire balloon (wiring attempt time was 6 min). A Venture catheter (St. Jude) was subsequently positioned proximal to the lesion, and the tip was flexed to point toward the occlusion. A Runthrough wire (Terumo) was then advanced through the Venture catheter and, in spite of forming a distal loop, successfully crossed the lesion into the mid circumflex ( Fig. 1 D), which had heavy thrombus burden and marked tortuosity ( Fig. 1 E). The crossing time with the Venture catheter (St. Jude) was 2 min. The lesion was predilated with a 2.0-mm balloon with improvement of antegrade flow. We were unable to advance a rheolytic thrombectomy catheter, in spite of using a buddy wire (Ironman; Abbott Vascular), but were able to advance a 6-French mechanical aspiration catheter (Fetch; Possis Medical, Minneapolis, MN, USA) to aspirate a large amount of thrombus. The lesion was successfully stented with three overlapping sirolimus-eluting stents (Cypher; Cordis, Warren, NJ, USA), with an excellent final angiographic result and Thrombolysis In Myocardial Infarction (TIMI) 3 flow ( Fig. 1 F). The patient had an uneventful recovery and remained asymptomatic during 2-years of follow-up.
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Case 2
A 64-year-old man with diabetes, hypertension, atrial fibrillation and prior stroke presented with anterior STEMI ( Fig. 2 A ). Diagnostic angiography demonstrated ostial occlusion of the LAD ( Fig. 2 B). We were unable to wire the LAD in spite of using an Asahi soft and a Pilot 200 wire (Abbott Vascular), because the wires entered the circumflex artery (attempt time, 4 min). A rapid exchange Venture catheter (St. Jude) was advanced in the proximal LAD and provided additional support enabling lesion crossing with a Runthrough wire (Terumo) ( Fig. 2 C) within 1 min. Following balloon predilation, rheolytic thrombectomy and implantation of a 3.0×15-mm everolimus-eluting stent (Xience V; Abbott Vascular), TIMI 2 antegrade flow was achieved, suggestive of no reflow ( Fig. 2 D). Echocardiography, following percutaneous coronary intervention, demonstrated anterior wall akinesis and an ejection fraction of 20%. The patient had a long hospitalization complicated by cardiogenic shock requiring intra-aortic balloon pump and inotropic support, respiratory failure requiring intubation and eventually tracheostomy, and recurrent infections.
2
Case 2
A 64-year-old man with diabetes, hypertension, atrial fibrillation and prior stroke presented with anterior STEMI ( Fig. 2 A ). Diagnostic angiography demonstrated ostial occlusion of the LAD ( Fig. 2 B). We were unable to wire the LAD in spite of using an Asahi soft and a Pilot 200 wire (Abbott Vascular), because the wires entered the circumflex artery (attempt time, 4 min). A rapid exchange Venture catheter (St. Jude) was advanced in the proximal LAD and provided additional support enabling lesion crossing with a Runthrough wire (Terumo) ( Fig. 2 C) within 1 min. Following balloon predilation, rheolytic thrombectomy and implantation of a 3.0×15-mm everolimus-eluting stent (Xience V; Abbott Vascular), TIMI 2 antegrade flow was achieved, suggestive of no reflow ( Fig. 2 D). Echocardiography, following percutaneous coronary intervention, demonstrated anterior wall akinesis and an ejection fraction of 20%. The patient had a long hospitalization complicated by cardiogenic shock requiring intra-aortic balloon pump and inotropic support, respiratory failure requiring intubation and eventually tracheostomy, and recurrent infections.
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