Dual Coronary Artery Thrombosis: An Unforeseen Angiographic Encounter

Acute myocardial infarction (AMI) frequently involves single-vessel coronary artery disease, but simultaneous thrombosis in multiple coronary arteries is a rare and challenging clinical scenario. We report the case of a 42-year-old Southeast Asian male with a six-month history of hypertension controlled by a single antihypertensive agent, presenting to the emergency department with central chest pain radiating to the back. The initial electrocardiography (ECG) showed ST elevation in the inferior leads. Primary percutaneous coronary intervention (PCI) via the right femoral approach revealed complete thrombotic occlusions in the left anterior descending (LAD) and right coronary artery (RCA). Drug-eluting stents (DES) were deployed, restoring thrombolysis in myocardial infarction (TIMI) III flow. Despite initial hemodynamic stability, the patient experienced cardiogenic shock (CS), necessitating a relook angiogram that confirmed patent stents and identified an additional stenosis in the first diagonal branch (D1). An intra-aortic balloon pump (IABP) was inserted. The patient's course was complicated by recurrent CS, septic shock secondary to Fusobacterium periodonticum bacteremia, acute kidney injury, multiple supraventricular arrhythmias (SVTs), and partial thrombosis of the right radial artery leading to dry gangrene of the right index and thumb fingers. He was eventually discharged on oral warfarin for radial artery thrombosis and paroxysmal atrial fibrillation with follow-up care with vascular surgery.