case_images: PMC10166827_01
case_images: ECG in the ER before the coronary angiogram. ECG showing AF, complete heart block, junctional escape rhythm, and ST-segment elevation in leads II, III, aVF, and V3R-V5R.
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case_images: F1
case_images: An electrocardiogram showed atrial fibrillation (AF), complete heart block, junctional escape rhythm, and ST-segment elevation in leads II, III, aVF, and V3R-V5R (Figure 1).
case_images: Coronary angiogram. The initial view of the coronary angiogram in (A-C) revealing a normal left coronary system and an embolism in the proximal right coronary artery (dark arrow): (A) Cranial 30, (B) RAO 30 + Caudal 30, (C) LAO 40. (D) Hourglass sign of balloon angioplasty. (E) Embolus in the proximal right coronary artery (dark arrow). (F) Right coronary angiogram showing TIMI 3 blood flow after the intervention.
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case_images: F2
case_images: An emergency coronary angiogram showed a total occlusion of the proximal right coronary artery (RCA) with a globular filling defect without any collateral vessels from the left coronary system (Figure 2). Then, we used a Sprinter balloon of different sizes (2.0 x 20 mm and 2.5 x 15 mm) (Medtronic, USA), which successively dilated the lesion, and an hourglass sign was revealed (Figure 2). TIMI 1 and the embolus ran deeper into the RCA (Figure 2). To make the characteristics of the embolus clear, we decided to perform intravenous ultrasound (IVUS) (Boston Scientific, USA).
case_images: Intravenous ultrasound (IVUS). IVUS showing calcification and posterior echo attenuation in the middle RCA (white arrow).
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case_images: F3
case_images: IVUS showed calcification and posterior echo attenuation in the mid-RCA (Figure 3).
case_images: Angioguard umbrellas in both carotid arteries.
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case_images: F4
case_images: Angioguard (6 mm) umbrellas (Cordis, USA) were inserted in both carotid arteries through an 8-Fr MPA catheter (Cordis, USA) (Figure 4). A 2.5 x 15 mm Sprinter balloon was successfully passed through the lesion and was inflated to 4 atm.
case_images: Lower limb artery angiography showing a filling defect (dark arrow) in the right peroneal artery.
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case_images: F5
case_images: Fortunately, we found that the embolus was brought to the right peroneal artery (Figure 5).
case_images: ECG after the procedure. ECG showing AF, and premature ventricular beats.
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case_images: F6
case_images: An electrocardiogram after the procedure revealed that the ST segment had returned to baseline and no significant Q wave was detected in the inferior leads (Figure 6).
case_images: (A) Photograph of the retrieved embolus: gray globular tissue with a diameter of 4 mm. (B) Photomicrograph of the embolus. Hematoxylin and eosin staining. At the center of the embolus is fibrinoid necrosis with a few mixed red blood cells, and the surrounding is a thick layer of fibrotic tissue with hyaline degeneration and peripheral calcification.
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case_images: F7
case_images: Fibrinoid necrosis developed at the center of the embolus with a few mixed red blood cells, and surrounding it was a thick layer of fibrotic tissue with hyaline degeneration and peripheral calcification (Figure 7).