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Use of Intravascular Ultrasound in Inferior STEMI Due to Type A Aortic Dissection
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A 57-year-old woman with good past health was admitted to the accident and emergency department at an outside hospital for sudden onset chest pain. Electrocardiogram revealed ST-segment elevation at the inferior leads (Figure 1). Primary percutaneous coronary intervention (PCI) was activated, and the patient was transferred to the catheterization laboratory in our unit for an urgent coronary angiogram.
On-table-focused echocardiogram showed a dilated aortic root with moderate aortic regurgitation, which raised suspicion of an aortic dissection. Six-French right radial access was obtained and the left coronary system was engaged with an IL-3.5 guide catheter, which was unremarkable. The right coronary artery (RCA) was engaged with some difficulty. Coronary angiogram demonstrated an anteriorly located dissection flap over the right coronary cusp with extension of the hematoma into the proximal RCA resulting in Thrombolysis in Myocardial Infarction (TIMI)-2 flow (Figure 2A, Videos 1 and 2). Intravascular ultrasound (IVUS) (Volcano, Philips) demonstrated the presence of a hematoma extending from the ostial to the proximal RCA, with its propagation probably hindered by a pre-existing calcified plaque at the proximal RCA (Figure 2B-D, Video 3). The coronary flow remained sluggish after serial balloon dilatation. In view of ongoing ischemic symptoms with persistent ST-segment elevation and after discussion with the on-site cardiothoracic surgeons at our hospital, our team decided to proceed with stenting to the RCA. A 3.5 x 24-mm drug-eluting stent was implanted at the proximal RCA, and ST elevation improved post-stenting. Final angiogram showed satisfactory flow to the RCA (Figure 3).
An urgent computed tomography aortogram taken immediately after the primary PCI revealed a Stanford type A aortic dissection. Urgent surgery for post-ascending aorta and hemiarch resection and replacement was performed with satisfactory hemostasis. The patient was discharged on day 12 and was well at the 1-month outpatient follow-up visit.
In cases of suspected aortic dissection presenting with ST-elevation myocardial infarction, the use of IVUS during primary PCI may provide valuable information about the nature and extent of dissection and hematoma. Discussion between interventional cardiologists and cardiothoracic surgeons is needed to decide on the optimal treatment strategy.
Affiliations and Disclosures
From the Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient prior to the interventions described in the manuscript.
Address for correspondence: Esmond Yan Hang Fong, MBBS, Division of Cardiology, Queen Elizabeth Hospital, Hong Kong SAR. Email: fongesmond@gmail.com; X: @esmondfong
