Acute Thrombotic Occlusion as a Complication of Functional Flow Reserve Measurement(FFR)Measurement(FFR)

Department of Cardiology Saga Prefectural Hospital Koseikan Saga Japan Saga Prefectural Hospital, Koseikan, Saga, Japan Arihide Okahara, Daigo Mine, Takaharu Shirahama,

Y t N t T t Shi i K iki Y hidYasutsugu Nagamoto, Tetsuya Shiomi, Keiki Yoshida, Kenji Sadamatsu

CASE

Age, Sex 76y.o. male

Chief complaint Chest pain at effort

Social history Non smoking or drinkingSoc a sto y

Family history Nothing paticular

Non smoking or drinking

Family history Nothing paticular

Past medical history Internal hemorrhoids Occasional bloody stool.y

Hi t f t illHistory of present illness

•He was admitted to our hospital for effort angina.

•He was underwent balloon angioplasty for the mid portionof the left anterior descending artery 16 years ago.of the left anterior descending artery 16 years ago.

•His coronary risk factors were hypertension anddyslipidemiadyslipidemia.

•The ECG and the echocardiography were normal.

•Thallium myocardial scintigraphy showed a reversible largesized perfusion defect in the LAD territory.sized perfusion defect in the LAD territory.

Left coronary angiography y g g p y

RAO-CAU RAO-CRARAO CAU RAO CRA

Severe stenotic lesions in the proximal LCx and the proximal LAD.

Right coronary angiographyg y g g p yLAO

A severe stenosis in the proximal RCA p

FFR to the LAD

We planned to evaluate FFR in all the 3 arteries toWe planned to evaluate FFR in all the 3 arteries to decide a treatment strategy.

After the calibration and the equalization of the qpressure wire,we inserted the wire in LAD through a 5-Frenchwe inserted the wire in LAD through a 5 French diagnostic catheter.

FFR to the LAD

FFR in the distal LAD FFR in the LMT

The waveform (red line) obtained through the diagnostic catheter ( ) g gwas damped.

LCAG after FFR

When we changed the catheter, he complained chest pain g p pand his ECG showed ST elevations in II, III, aVF, V5-6 leads, and ST depressions in I, aVL, V1-4 leads. LCAG revealed a total occlusion in the proximal LCX and the obtuse marginal artery.

PCI to the LCX

Guiding catheter: a 6-French BL3.0 Guide wire:Runthrough NS hypercoartg ypIVUS: Atrantis pro2

IVUS

10

IVUS Thrombus

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PCI to the LCX

IVUS showed fibrous plaque and thrombus, without dissection or plaque rupture. B ll S i t L d 3 0 15

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Balloon : Sprinter Legend: 3.0 x 15 mm

PCI to the LCX

Balloon angioplasty with a 3.0 x 15 mm balloon recovered

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g p yTIMI grade 3 flow .

PCI to the LCX

The obtuse marginal artery remained occluded, then we inserted another floppy wire.

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Guide wire: Sion blue

PCI to the LCX

We dilated the lesion with the balloon.Balloon: Sprinter Legend: 3.0 x 15 mm

15

p g

PCI to the LCX

The flow was not recovered, then we inserted a thrombectomy

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, ycatheter.

PCI to the LCX

We successfully retrieved a large thrombus.

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PCI to the LCXThe final LCA angiogram

Final angiogram showed a good result.

Time table

0 min •Dose of hepaine: 2000 units0 min

2 min

•Dose of hepaine: 2000 units

•LCAG2 min

4 min

•LCAG

•RCAG4 min

35 min

RCAG

•ATP start35 min

45 min

ATP start

•ST elevation45 min

73 min

ST elevation

•Aspiration of thrombus73 min

84 min

Aspiration of thrombus

•The end of PCI8 e e d o C

Take Home Messageg

•Give appropriate dose of heparin before FFR.

•Be careful for the waveform during FFR.