Author + information
- Received October 16, 2017
- Revision received November 17, 2017
- Accepted November 28, 2017
- Published online May 2, 2018.
- Pierluigi Merella, MD∗ (, )
- Giovanni Lorenzoni, MD,
- Nicola Marziliano, PhD,
- Graziana Viola, MD,
- Paola Berne, MD,
- Giovanni Motta, MD and
- Gavino Casu, MD
- ↵∗Address for correspondence:
Dr. Pierluigi Merella, Unità Operativa Complessa di Cardiologia, Ospedale San Francesco Nuoro, Via Mannironi 1, 07044 Nuoro, Italy.
- coronary embolism
- coronary optical coherence tomography
- retrograde coronary embolization
- retrograde embolus from infarct-related artery
A 66-year-old woman was rescued by emergency medical service for acute posteroinferior myocardial infarction (Figure 1A). At the hospital, the patient was asymptomatic with regression of ST-segment elevations (Figure 1B); an echocardiogram showed hypokinesia of the lateral wall of the left ventricle with normal ejection fraction (55%). The coronary angiography showed subocclusion of the proximal left circumflex coronary (LCx) artery (Figure 2A) and a large thrombus in mid-left anterior descending (LAD) coronary artery (Figure 2B, Online Video 1). The culprit lesion on the LCx was treated with coronary angioplasty with drug-eluting stent implantation (Figure 2C). After that, optical coherence tomography confirmed a large thrombotic formation in the mid-LAD with involvement of the diagonal branch (Figure 2D, Online Video 2). Images were compatible with a red thrombus without appearance of plaque erosion or ulceration. The thrombus formation was interpreted as a retrograde embolus from the LCx to LAD.
After ineffective attempts of thromboaspiration, we chose a medical therapy strategy. The patient remained asymptomatic and was discharged at home 5 days after.
Spontaneous reperfusion in the setting of ST-segment elevation acute coronary syndrome is reported in up to 30% of patients (1). Distal embolization is frequently signaled (2). Various reports demonstrate that thrombus may embolize causing coronary occlusion downstream in the dependent vascular territory.
Although retrograde embolization during coronary angioplasty is a well-known complication, this is the first demonstration to our knowledge of retrograde embolization from an infarct-related artery to a bystander “nonculprit” artery.
Although in this anecdotal case, the retrograde embolization led to spontaneous reperfusion, in other cases, it might have more dramatic consequences.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 16, 2017.
- Revision received November 17, 2017.
- Accepted November 28, 2017.
- 2018 American College of Cardiology Foundation