Case 40: PCI Manual - When everything goes wrong

A patient presented with inferior STEMI and was found to have severe lesions in the mid and distal RCA. Engagement of the RCA via right radial access was challenging resulting in acute vessel closure. Attempts to re-enter the true lumen failed, in part due to poor guide catheter support. Attempts to get access in the right femoral artery also failed, as the wire could not be advanced past the iliac artery due to calcification, tortuosity, and an iliac aneurysm. Left femoral access was obtained with repeat attempts to recanalize the RCA. The patient developed hypotension and pelvic fluorosopy revealed a displaced bladder, suggesting a retroperitoneal hematoma. A balloon was inflated in the right iliac artery but a covered stent could not be delivered. The patient developed ventricular fibrillation, requiring multiple defibrillations and eventually placement of VA ECMO (surgically in the right common femoral vein and percutaneously in the left common femoral artery). The RCA was subsequently recanalized using a knuckle to cross subintimally distal to the previously placed stents and a Stingray to re-enter into the distal true lumen. The patient had a prolonged hospital course but eventually recovered.

[@aq4019]

One of the worst nightmares that could ever happen to surgeons, hats off to all ur team,sir!

[@MinorityDoc]

Very difficult to bail the patient out in such a situation. Imagine, leaving a closed RCA to manage the access complication. While the patient arrests. Hats off.

[@moazAlhamedy]

Such an operative conundrum! Good job.

[@micger]

Wow what an amazing case! Thank you for sharing!

[@neeru.indian]

Great save.needs lot of guts and persistent efforts.

[@DrMusrafaduran]

It seems to me the patient discharged with very poor ejection fraction

[@wanjae]

This was never an easy case at anytime. I wonder sometimes we should think of using tpa especially radial access. Stabilize and then attempt in a controlled setting. Just a thought. Although great save.

[@progreviews]

How do you differentiate whether you are in the false or true Lumen?

[@manosbrilakis]

The following suggest true lumen wire position:
1. Workhorse wire moving easily without knuckling and entering side branches
2. IVUS
3. Transducing pressure through a microcatheter (advance microcatheter over wire, then remove wire)

[@rogeriomoura6557]

BEST ANGIOGRAPHIC RESULT BUT WHAT THE IMPROVEMENTS FOR PATIENT??IS THE DOUBT….NOTHING

[@dobryi_chel]

Unbelievable case! How much time passed from cardiac arrest to ECMO connection?

[@manosbrilakis]

Approximately 15 minutes.

[@dobryi_chel]

At what level was the blood pressure during a non-direct massage of the heart?