HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
The patient is a 67-year-old male, ex-smoker with an accumulated rate of 50 packs/year, hypertension, dyslipidaemic and diabetic on insulin treatment, with a history of high-risk STEMI in February 2015 and implantation of three paclitaxel-eluting stents in the middle and distal right coronary artery (RCA) (Luc-Chopin®: 3x12 and 2.5x12 mm respectively), and in second time two other stents (Luc-Chopin®: 3x12 mm and 2.5x12 mm) to proximal anterior descending (AD) and middle. In October 2015, due to anginal symptoms, angiographic re-evaluation documented severe restenosis of previous stents, so new percutaneous resvascularisation was performed with implantation of three everolimus-eluting stents (XIENCE PRIME®), one in the proximal LAD (3x18 mm) and two overlapping stents in the middle and distal DC (3x28 mm, 2x25 mm).
Having been asymptomatic for the last two years and taking double antiplatelet therapy with aspirin and prasugrel, on the day of admission he consulted for typical chest pain of 1.5 hours' duration.
Physical examination revealed ERW. Mucocutaneous pallor. Normoperfused and normohydrated. Vitals: BP: 170/80 mmHg, O2 Sat: 96 % (GFN at 2 bpm).
Afebrile. Jugular ingurgitation at 45o. Cardiac auscultation: rhythmic, no murmurs or friction sounds. Pulmonary auscultation: diminished vesicular murmur, with crackles up to midfields, expiratory wheezing and rhonchi. Abdomen: nondescript. Lower extremities: no oedema. Positive and symmetrical pulses at all levels.

COMPLEMENTARY TESTS
ECG on admission: sinus rhythm. Normal PR. rS from V1 to V3. ST ascended 4 mm V3-V4, 1-2 mm inferior and 1 mm in V5. ST underleveled in V6, I, aAVL. T sharp V3-V4. T +/- inferior.
CBC: biochemistry: 170, urea 106, creatinine 1.50, sodium 132, potassium 4.5. Chlorine 95, GOT 27, LDH 1022, CK 156: Coagulation: normal. CBC: erythrocytes 3.64, haemoglobin 12, Ht 34.8, haemoglobin C.M 31.2. Platelets 363,000, MCV 10.3, lymphocytes 19.6. E 3,8. Maximal serial myocardial necrosis enzymes: TTUS > 10,000, CK/MB 5600/566.
Chest X-ray: increased CTI. Signs of COPD. Prominent hilarity with redistribution.
Urgent echocardiogram: Non-dilated LV. Mild LVH. Severely depressed LVEF (25-30 %). Akinesia of inferior, apical and septal segments. Hypokinesia of basal and anterior middle segments. Normal CCDD, with good function.
Normal LA. Normal Ao root. No DP. Mild MI
Urgent catheterisation (right radial): left coronary: thrombotic occlusion of the stent in the proximal LAD. Severe stenosis in distal edge of stent is observed after opening. Severe disease of bisector branch of borderline calibre. Severe stenosis of distal Cx in small calibre vessel. Right coronary: dominant. Thrombotic occlusion of the middle and distal DC stent. PCI with thrombectomy and balloon PTCA on mid and distal DC stent thrombosis, and on proximal and mid LAD stent thrombosis. PCI with direct stent implantation of a 2.75 mm diameter, 12 mm long XIENCE PRIME direct coated stent at 13 atmospheres in the middle LAD (distal edge of previous stent).

EVOLUTION
The ECG showed anterior and inferior ST elevation, the echocardiogram showed akinesia of inferior, apical and septal segments with severely depressed systolic function (LVEF 30%). Urgent coronary angiography documented thrombotic occlusion of stents in the proximal LAD and also of stents in the mid and distal DC, thrombectomy and balloon angioplasty were performed on the proximal LAD and mid and distal DC, intracoronary abciximab was administered, achieving a good final angiographic result with TIMI III flow (Video 4). When restenosis of the distal edge of the middle LAD stent was found, it was decided to implant a DES (XIENCE PRIME®: 2.75x12 mm). The patient evolved favourably, a hypercoagulability study was performed, which was negative, and he was discharged in NYHA CF II, with treatment with aspirin (100 mg per day) and prasugrel (10 mg per day).
After 4 months, he was readmitted for unstable angina, and a new coronary angiography was performed which showed severe restenosis of the proximal edge of the DES (Luc-Chopin®) from the first procedure in the proximal LAD (Video 5). After discussing the case in a medical-surgical session, surgical revascularisation was decided and a single coronary bypass of the internal mammary artery (IMA) to the LAD was performed, but the patient had a torpid postoperative period complicated by respiratory infection and finally died of refractory septic shock

DIAGNOSIS
Extensive anterior + inferior STEMI, k II. Urgent catheterisation with late double thrombosis of stents at the level of the middle DC and proximal LAD.
Thrombectomy, PTCA at mid and distal DC and proximal LAD. Implantation of everolimus-coated stent at the level of distal edge restenosis of mid LAD stent. Severe disease of distal CX and small-bore bisetrix.
Severe restenosis of DES implanted in proximal LAD. Surgical revascularisation with IMA to LAD. Torpid postoperative course. Exitus.
LVEF of 45%.
HYPERTENSION. Diabetes mellitus (DM) type 2. DLP. Ex-smoker.
