Seunghwan Kim, Sang–Hoon Seol,*, Dong–Hee Park, Yun–Seok Song, Dong–Kie Kim, Ki–Hun Kim,Doo–Il Kim, Pil–Sang Song

1Department of Internal Medicine, Haeundae Paik Hospital, Inje University college of Medicine, Busan, Republic of Korea

2Department of Internal Medicine, Se-Jong General Hospital, Incheon, Republic of Korea

Simultaneous thrombosis affecting more than one coronary artery has been reported to occur in about 4.8% of the cases at the time primary percutaneous coronary intervention (PCI).[1]Simultaneous multiple coronary arteries thrombosis is uncommon and can lead to a fatal outcome. Careful attention should be given to identification of abnormal ECG and coronary angiography (CAG) results. The affected vessel should be opened timely and efficiently in an effort to save the myocardium and reduce serious complications such as congestive heart failure, ventricular arrhythmia, cardiogenic shock, or sudden cardiac death.

A 64-year-old male presented to our emergency department due to severe chest pain. He did not have a history of atrial fibrillation before the acute coronary event. The auscultatory findings of the physical examination included galloping rhythm (S4) with no murmurs, and his blood pressure was 60/40 mmHg. The ECG showed complete atrioventricular block and heart rate of 45 beats per minute with ST segment elevation in leads II, III, augmented vector foot(aVF) and V2–3(Figure 1). Emergent CAG revealed an obstructing thrombus in the proximal part of the right coronary artery (RCA) (Figure 2A) as well as total occlusion in the left anterior descending (LAD) coronary artery (Figure 2B).Right endo-ventricular temporary pacing via right femoral vein was immediately started. We firstly treated the lesion in the RCA with balloon that was followed with the deployment of a 4.0 × 28 mm biolimus-eluting stent (BES),with an excellent angiographic result (Figure 3A). Thereafter, we aspirated the thrombus in the LAD coronary artery.After aspiration of the thrombus, we could find plaque rupture in LAD artery by intravascular ultrasound (Figure 4).The LAD artery recanalization by manual thrombus aspiration, balloon angioplasty, and stenting with a 3.5 × 18 mm BES was inserted (Figure 3B). The patient’s laboratory tests,which included antithrombin III, protein C, protein S deficiencies, and activated protein C resistance, did not indicate any coagulation disorders. Lupus anticoagulant, anticardiolipin IgM and IgG were also negative. The patient’s platelet count was 162,000/mm3. A transthoracic echocardiography was performed, and akinesia of the mid and apical portions of the inferior wall, hypokinesia of the anterior and anteroseptal wall were found. Estimated left ventricular ejection fraction was 44%, and there were no intra-cardiac shunt and no intra-cardiac thrombus suggestive of an embolic source. He was discharged seven days later in stable condition with aspirin, ticagrelor and rosuvastatin. We report a case of 64-year-old male who was admitted to our hospital due to ST segment elevation myocardial infarction(STEMI), and found to have thrombotic occlusion of two major coronary arteries.

Figure 1. ECG showed complete atrioventricular block with ST segment elevation in leads II, III, aVF and V2–3. aVF: augmented vector foot.

Figure 2. Coronary angiography revealed thrombus in the proximal part of the right coronary artery (A), and total occlusion in the left anterior descending coronary artery (B).

Figure 3. After percutaneous coronary intervention, coronary angiography demonstrated no residual stenosis right coronary artery (A), and left anterior descending coronary artery (B).

Figure 4. Intravascular ultrasound showed plaque rupture in left anterior descending coronary artery.

STEMI is typically caused by disruption of atheromatous plaques, resulting in thrombus formation leading to partial or complete occlusion of coronary artery. Thrombosis of multiple coronary arteries at the same time is an uncommon angiographic finding during the course of STEMI. Simultaneous multi-vessel coronary thrombosis can occur secondary to causes (e.g. coronary artery spasm, cocaine abuse,increased tendency to thrombosis, anti-thrombin III deficiency, idiopathic thrombocytopenic purpura, as well as thrombophilias such as antiphospholipid antibodies, factor V Leiden deficiency, and essential thrombocytosis).[2]However, the underlying mechanism still remains unclear in most of these patients, as in our case. Multiple plaque rupture has been postulated as the main theory behind the cases without an identifiable cause. At least in some patients,acute coronary event reflects a diffuse pathophysiologic process that may lead to multifocal plaque instability associated with clinical instability at multiple sites. Although the incidence of angiographically multiple coronary arteries thrombosis is thought to be low in real practice, the percentage of patients with STEMI that had presentation of thrombus in the non-culprit lesion was 32.8% in an angiographic study.[3]Furthermore, an autopsy study revealed that thrombosis was evident in more than one coronary artery in up to 50% of the cases of sudden death.[4]Cardiogenic shock or sudden cardiac death was the most common clinical presentation occurring in about 40%–50% of the patients, followed by ventricular arrhythmia.[5]Recently,there are reports that balloon angioplasty and thrombus aspiration result in better reperfusion in case of RCA and LAD thrombosis than those treated with stents.[6]In our case,we treated cardiogenic shock patient with LAD artery thrombus aspiration, ballooning and stent insertion without complication. Early diagnosis and proper treatment are the most important factors in the management process. Early diagnosis involves the timely and accurate performance of ECG and echocardiography. At the same time, it should always be kept in mind that coronary arteries must be examined properly during PCI, especially if the patient presented with cardiogenic shock or sudden cardiac arrest, or if multiple coronary arteries are suspected to be the cause.Some patients need aggressive therapy such as intra-aortic balloon pump or extracorporeal membrane oxygenation.[7]In summary, simultaneous multiple coronary arteries thrombosis occurring in a patient with STEMI is rare but it can lead to fatal complication. More studies about risk factors,treatment, prognosis, complications of simultaneous thrombosis affecting more than one coronary artery are needed.

References

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