Thursday, December 12, 2013

Subacute Stent Thrombosis in a 28 Year-Old : Use Of Export Aspiration Catheter

28 year old, Ghazali al Ghazali [ not his real name of course ! ], long-haired, pony-tailed, a messenger with the local DHL, chronic smoker with familial hypercholesterolamia [ meaning 'high lipid level' largely due to genetic component ], had had a drug eluting stent implanted in Damansara Specialist Hospital just four months ago for a longish 90 % narrowing in his dominant right coronary artery. His left coronary was no better but stent implantation on the left side, I assume, was not possible or ideal as his left was grotty looking with diffuse disease both in the Left Anterior Descending branch as well as the Circumflex branch. The left coronary, if considered singly , is only good for optimization of medical therapy. His right culprit artery is dominant plus plus. And there lies the interventionalist's problem and potential nightmare.  He  has very  little leeway to play around due to very little cardiac reserve. In 'interventionalist' parlance... a distinct case of 'no insurance policy' to fall back on if things do not go the way he plans.

Oh dear ! When you have this kind of 'coronary tree' at 28, your future is not too bright.....
His cardiologist put him on a high dose ' statin ' to bring down his lipid level. and DAPT [ dual anti platelet therapy] ie Plavix and aspirin to give adequate 'thinning' of his blood. He ran out of medication for two weeks and this wee hours of the morning at 1 am,  landed at our doorstep at ER, SDMC with what appear as an acute inferior myocardial infarct. My provisional diagnosis is an acute Myocardial Infarction [ heart attack ] due to subacute stent thrombosis meaning, an MI arising from blood clot formation in the stent. He was in pain plus plus, clutching his chest and despite double dose of IV morphine, still no abatement of pain.  Not a good sign, the territory and the vessel involve must be massive. Time is the essence.

We immediately brought him to the Cath lab and perform an emergency coronary angiogram. ] . At angiogram, I noted that my provisional diagnosis and suspicion was right . There was total occlusion prior to the stent in the right coronary artery. I could easily pass a 14/1000 inch guide wire across the occlusion. This guide wire act like a life giving railway line across the occluded artery providing a base for me to pass a balloon or stent across.
If one cannot get the guide wire across, one cannot perform balloon angioplasty or stenting. For us in the 'business', getting the guidewire across the occlusion is the 1st single most important step to a  successful procedure. [ ]. No wire across, no work done

In Ghazali's case, since the initial angio film showed a chokerblock full of blood clots, I did not pass a balloon to open up the lesion. I change my technique to using the Export Aspiration Cathether, passing it to the blocked portion of the artery, by sliding it along the guidewire. ]. I made altogether three complete 'passes' across the blocked artery and suck out almost all of  the clot.

In the final angio film the artery looked fairly respectable with only some tiny clots left here and there. The stent that was implanted four months ago look very well deployed by my colleague in Damansara, so putting another stent across the old one, in Ghazali's case , in my opinion would not be necessary, and in fact would be counterproductive. Instead I gave a shot of an anti thrombolytic agent[ Rheopro ]  directly into the coronary.

Ghazali was a bundle of nerve plus plus when we started the procedure despite two initial boluses of morphine IV. Missing two weeks of plavix and cardiprin was his undoing
I managed to cool him down by divine help.
" Ghazali, I want you to concentrate on your zikrullah or kul huwallah all the time while iIconcentrate on my work ". It did wonders. I find it always help to have a 'Third Person' helping you in cases like this !

In Ghazali's case now, a young man  of 28 with two heart attacks already under his belt, with a left ejection fraction of only 30 - 40 % [ normal being 60 to 80 % ], in future,  I could see that I have to address the issue of his 'soul '.
And this is the difficult and touchy part. I have to thread carefully here.
Him, being Muslim make my job easier.

" No more' korner' baring please... !  and be friendly with the local mosque..."

Nik Howk

Related Articles in the blog :

Prayer of the Righteous

Young Deaths...

'Jangan Korner Baring' : Unto Him Is The Journeying

No comments: