Unmasking Culprit Complex Infero-Posterior STEMI

Figures

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  Figure 1. Presenting Electrocardiogram With ST-Segment Elevation Myocardial Infarction ST-segment elevations in the inferior leads and reciprocal changes in the anterolateral leads. Note the pattern of ST-segment depressions in V1 and V2, suggestive of posterior wall involvement.

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  Figure 2. Diagnostic Angiogram With Bypass Angiography (A) Left coronary angiogram. Varying degrees of disease, with left main free of flow-limiting issues, mild disease in the left circumflex and the first obtuse marginal artery (30%), and diffuse stenosis in the left anterior descending artery (proximal 30%, mid 50%-60%, and distal 30%). (B) Patent left internal mammary artery. Diagonal branch filling patent bypass. Septal and epicardial branches filling the right posterior descending artery (rPDA) chronic total occlusion (CTO). (C) Occluded saphenous vein graft (SVG). Bypass angiography revealed extensive thrombus burden of the SVG to rPDA. (D) rPDA CTO. Right coronary artery is patent with stents, but the rPDA is chronically occluded and filled by collaterals from the left anterior descending artery, while a previous SVG to this area is also occluded.

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  Figure 3. Native Right Coronary Artery Chronic Total Occlusion Up to the Bifurcation Microcatheter injection of distal right system showing a large trifurcated right posterolateral artery branch.

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  Figure 4. Attempted Mechanical Aspiration Thrombectomy Unsuccessful due to the extremely high thrombus burden.

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  Figure 5. Ad Hoc Right Coronary Artery Chronic Total Occlusion Intervention With Reverse CART and Tip-In Technique (A) Reverse coronary artery revascularization therapy (CART) for chronic total occlusion. Performed reverse CART using an antegrade 3.5-mm balloon. (B) Tip-in technique. Reentered the true lumen antegrade with a Confianza wire using the tip-in technique.

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  Figure 6. Successful Revascularization of RCA and rPL Chronic Total Occlusion The CTO lesion was predilated and stented from the mid to distal right coronary artery (RCA) into the right posterolateral artery (rPL) branch, resulting in TIMI flow grade III to the RCA and rPL trifurcation.

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  Figure 7. Follow-Up Staged Revascularization of rPDA CTO The final result of staged retrograde rPDA CTO revascularization. Final right coronary artery (RCA) angiography revealed TIMI flow grade III from the RCA to right posterolateral artery and rPDA. Abbreviations as in Figure 2.