Case 54: PCI Manual - Knuckle wiring for STEMI

A patient presented with inferior STEMI with thrombotic occlusion of the mid right coronary artery. A knuckled Sion Blue guidewire was successfully advanced through with occlusion, followed by thrombectomy with an Export catheter, retrieving a large amount of red and white thrombus and restoring TIMI 3 antegrade flow. Administration of nitroglycerine and nicardipine increased the lumen size, followed by successful stent implantation. A concomitant lesion in the LAD was not treated during the emergent procedure but was postponed for a later time.

[@AhmedElborae]

Thank you Dr Manos. I did it a couple of days ago in a patient with Inf.STEMI ,post cardiac arrest in VF with tough proximal RCA thrombus and it helped me in restoration of flow within seconds.

[@shangz0216]

Thanks for your educative presentation.

[@mohamedadam9391]

Thank you sir we need more videos elaborating tips and tricks of wire tip shaping in different lesions subsets

[@BarrieLouis]

very interesting case!

[@salahuddinsalahuddin3210]

Thanks

[@ahmedsabbar9049]

Thank u very much for sharring this intetesting case, I wonder whither the second stent is deployed at a distance from the first one.

[@manosbrilakis]

Yes it was - there were 2 separate lesions.

[@ahmedbasheer8156]

thanks for this meticulous presentation but I am compatible with dr.ahmed sabbath that there is residual stenosis between two stents may become focus for future denote stenosis

[@JCT75]

@@ahmedbasheer8156 I am sure the residual stenosis is hemodynamically insignificant.

[@farukakturk5388]

Sir while knuckling how can we ve süre that we are not going subintimally?

[@manosbrilakis]

Good question: to minimize the risk for subintimal guidewire entry a workhorse guidewire should be used, the knuckle should be formed before reaching the occlusion, and forceful wire advancement should be avoided.

[@farukakturk5388]

@@manosbrilakis thank you very much for your reply.

[@doc-rdx]

such occlusions have RVMI associated with this. sir, would you still use i/c ntg in this ?

[@manosbrilakis]

Good point. If you have signs/symptoms of right ventricular MI I would not use nitroglycerin. This patient did not have such symptoms.

[@tuanhoanh1198]

Thank you so much for your sharing. I have several questions. 1. when the thrombus is large but the vessel lumen can still be estimated, should we perform direct stenting with moderate pressure on inflation, leaving that with acceptable TIMI 3 flow and come back to check +/- correct the stent in the second procedure in 5-7 days later? how about the risk of stent thrombosis in that handling? 2. when the thrombus can not be broken, operator can not restore the flow even after manual aspiration, what should we do? should we treat with eptifibatide and carry out coronary angiogram 2-3 days later? especially in case of cardiogenic shock?

[@manosbrilakis]

1. I would do thrombectomy first in this case and then stent without FU cath. 2. Consider laser - consider CABG if the surgeon would take the patient. If this fails IIb/III and FU angiogram appear reasonable.

[@tuanhoanh1198]

@@manosbrilakis i really appreciate your sharing

[@tuanhoanh1198]

NITRATE is not effective in resolving no reflow phenomenon but Nicardipine is useful while both have the effect to dilate the vessel. What is the difference, Professor?

[@manosbrilakis]

Nitrate dilates more the bigger vessels whereas nicardipine dilates more the microvasculature.

[@tuanhoanh1198]

@@manosbrilakis thank you very much for your reply

[@vt3635]

I would avoid knucle cause of thrombus dislodgment

[@durgaprasad-nv2cd]

Thank you very much sir, please help me when can we expect release of manual of PCI

[@manosbrilakis]

Mid 2020

[@durgaprasad-nv2cd]

Thank you sir

[@urHeartDr]

Manual available?