On the third day of admission, the patient was brought to the emergency Cath lab for revascularization. To enhance cardiomyocyte status before surgery, oral anticoagulants, lipid-lowering medication, and dual antiplatelets were given, as well as eptifibatide and nicotinamide IV injections, and blood pressure was 130/80. By using a right radial approach, 3000u of heparin sodium and 200ug of nitroglycerin were infused. The RCA ostium was reached with a SAL1.0 catheter, and angiography showed a 100 % acute total occlusion at the proximal end of the RCA, with a TIMI 0 forward blood flow (Figure 2A).
After 15 min of the procedure, the patient experienced sudden involuntary resistance in the left upper and lower limb activity with frequent head raising, and slurred speech, blood pressure was 133/85. According to the above clinical symptoms and signs, the patient was initially diagnosed with acute cerebral embolism. Given that the patient's vital signs were normal, but the RCA had a life-threatening subacute complete occlusion, the cardiologists recommended that the RCA be opened first to maintain heart perfusion before treating the cerebral embolism. After 5000u of heparin sodium was injected, a 2.0mm x 15mm balloon was inflated in the upper and middle parts of the RCA. Angiography revealed that the RCA still had no-reflow, indicating that the occluded segment was near the RCA's opening. Two 3.5x16mm and 3.0x28mm stents were inserted into the RCA's proximal end respectively. Although blood flow was restored, the middle and distal segments remained more than 90% occluded. A 3.0x24mm stent was placed in the middle of the RCA, and the RCA's forward blood flow reached a TIMI 3.
After 20 minutes of the occurrence of stroke, the neurologist decided to perform a CT scan first, which revealed acute cerebral thrombosis without hemorrhage. Cerebral angiography via a right femoral approach revealed an acute occlusion of the right middle cerebral artery (MCA) (Figure 3A). A stent retriever device was inserted along the entire length of the occlusion, and a tissue fragment measuring 0.5x0.4x0.3 cm was extracted. The right MCA was successfully revascularized within 50 minutes after the stroke occurred (Figure 3B), and the tissue was sent for analysis where it was identified as a fragment tissue thrombus (Figure 3C,3D).
After mechanical thrombectomy, the cardiologist decided to complete RCA revascularization as there was severe stenosis in the distal part of the right RCA. The RCA was revascularized with TIMI 3 blood flow after a 2.5x13mm Lacrosse balloon was inflated first, followed by two drug-coated balloons (DCB) (2.5.5x20mm,2.75x31mm) along the occluded segment. (Figure 2B)
The staged method for non-culprit lesions has improved short and long-term survival and should remain the standard approach for primary PCI in AMI patients [5]. The team decided to revascularize the left coronary vessels after a few days because a single complete multivessel recanalization may be linked to increased risks of renal failure. Three days after rehabilitation, the patient had normal eye movements whereas extremity movements occurred within 5 weeks.
The LAD and LCx vessels were recanalized a week later. In order to avoid secondary cerebral embolism caused by the radial artery approach, the femoral artery approach was selected. Angiography showed that there were multiple atherosclerotic plaque lesions along LAD, 70% stenosis of the diagonal D1 orifice, and chronic occlusion of proximal LCx with forwarding blood flow TIMI 1. (Figure 4A).
In the proximal LAD, a 2.5x13mm Lacrosse balloon was inflated, and a 15x15mm balloon was in the D1 orifice. Then, two (2.75x16mm, 30x16mm) stents were sequentially inflated in the proximal end and a 2.0x31mm DCB in the distal end. Angiography showed normal TIMI3 forward blood flow. At the proximal end of LCx, CSW135 microcatheter penetrated the occlusion. A 1.5x15mm balloon was inflated in the proximal segment OM1 and LCx, then two (2.0x24mm, 2.0x16mm) DCB were released along the proximal LCx. Angiography showed that the stenosis was relieved and forward blood flow was TIM3. (Figure 4B) After surgery, the patient was stable and safely returned to the ward.