Multifocal Plaque Rupture and Diffuse Pan-Coronary Instability Manifesting as Simultaneous Two-Vessel Myocardial Infarction: Case Report

ST-segment elevation myocardial infarction (STEMI) secondary to the acute, simultaneous thrombotic occlusion of two or more major epicardial coronary arteries constitutes a catastrophic and rare cardiovascular emergency (incidence 1.7%–4.8%) associated with a state of diffuse pan-coronary instability and cardiogenic shock. We present the case of a 57-year-old male patient with a medical history of hypertension and type 2 diabetes who presented to the emergency department of a secondary-care hospital with acute coronary syndrome. The initial electrocardiogram confirmed an acute anterior STEMI. Following failed pharmacological thrombolysis, the patient developed subsequent ST-segment elevation in the inferolateral leads, prompting urgent coronary angiography. Angiography demonstrated complex multivessel coronary artery disease. Urgent ad hoc percutaneous coronary intervention was performed on the culprit vessels via the deployment of two overlapping drug-eluting stents in the left anterior descending artery and one stent in the distal left circumflex artery, achieving angiographic success with final TIMI 2/3 flow and adequate myocardial perfusion while staging the right coronary artery lesion. In conclusion, simultaneous thrombotic occlusion of two major vessels is a highly lethal entity that underscores the phenomenon of multifocal plaque rupture. In the presence of electrical and hemodynamic instability, urgent primary percutaneous coronary intervention of the culprit vessels represents the most effective rescue therapeutic strategy, proving feasible and successful in secondary care centers equipped with cardiac catheterization laboratories.