Chest ache | Figure 1

kjames618
Paramedic

Case Summary

Chief Complaint

Chest ache

History of Present Illness

Approximately 60’s F, chest ache x20 minutes radiating down left arm and into back, constant, 5/10, then became diaphoretic and called 911.

Medical History

• History: COPD, hypertension
• Medications: losartan, albuterol, spiriva, HCTZ
• Allergies: sulfa, PCN

Assessment

• 324 ASA, refused pain management including fentanyl and Nitro
• Vital Signs: HR 80 - 110 bpm, BP 110/70, F 16-22, SPO2 99 RA, glucose 91
• STEMI called in field, cancelled by ER doc, reactivated by cardiology
• Troponin Levels:
  • Trop 1: 81
  • Trop 2:188
  • Trop 3: 240

Catheterization Laboratory Results

1. Left Main: Bifurcates into LAD and LCX. No angiographic significant disease.
2. LAD: Normal anatomic course, gives to diagonal branches. No angiographic significant disease.
3. LCX: Normal anatomic course, gives to OM branches. No angiographic significant disease.
4. RCA: Normal anatomic course, gives to PDA and PLV branches. Acute total occlusion proximal RCA.

Dominance: Right

PCI Details

• Lesion # 1: Proximal to mid RCA
• Anticoagulation with heparin to achieve target ACT > 250 sec
• Antiplatelet therapy, loaded with ASA and Ticagrelor.
• Guide Catheter: JR4 used to selectively engage the coronary artery under fluoroscopy.
• Guide Wire: Whisper wire in RV marginal and Runthrough in distal RCA wire used to cross the lesion under fluoroscopy.
• Balloon: 2.5 * 12 mm advanced to lesion site, inflated at 18 ATM.
• Stent Deployment:
  • Synergy 2.75 x 12
  • Onyx 3.0 x 38
  • Xience 3.0 x 8
  • Onyx 3.0 x 8 mm
• Post-stent balloon dilation with 3.25 NC Balloon at 18 ATM. IVUS confirmed stent fully expanded and well apposed.

Intervention Outcomes

• Pre-intervention: 100% occlusion, class C, TIMI 0
• Post-intervention: 0% residual stenosis and TIMI 3 flow
• Closure: Artery closure with radial compression band
• Immediate Post Procedure Access Site: No hematoma, distal pulse unchanged
• Complications: None
• Estimated Blood Loss: Minimal
• Specimen: None

Conclusion

Successful PCI to acute total RCA occlusion with 4 overlapping drug-eluting stents post dilated with 3.25 NC. IVUS guided intervention.

Diagnosis added by author

100 percent occlusion RCA (STEMI/OMI)

Case Reports & Images

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