case_images: PMC8142356_01
case_images: a. The electrocardiogram showed minimally diffuse ST segment depressions of 0.5mm in the lateral leads (I, aVL, V3-V6). b. Nomalization of ECG on third day of admission, 48 hours after continuous administration of the glycoprotein IIb/IIIa inhibitor Abciximab.
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case_images: F1
case_images: The electrocardiogram showed minimally diffuse ST segment depressions of 0.5mm in the lateral leads (I, aVL, V3-V6) (Fig. 1a). Blood tests revealed an elevated creatinine phosphokinase (CPK: 581U/I, normal range: <196U/I), and elevated high sensitivity troponin T (hsTNT: 0.954 ng/ml, normal range: <0.014 ng/ml), while myoglobin and CK-MB were in the normal range (Fig. 1b).
case_images: a. Coronary angiogram showing occluded aneurysmatic circumflex artery. b. Large thrombus burden, wiring of the circumflex failed initially even with balloon back-up. c. After successful placement of the wire in the distal circumflex, multiple attempts to manually aspirate and dilate the blood vessel failed to open the occluded artery.
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case_images: F2
case_images: Accordingly, the patient was diagnosed with Non-ST-Elevation Myocardial Infarction (NSTEMI), loaded with 500mg of acetyl salicylic acid, a bolus dose of heparin (5000 IU) and underwent a coronary angiography, which showed an occlusion of what seemed a markedly aneurysmatic circumflex artery with a diameter of up to 6.2mm just after the bifurcation of the posterolateral branch. (Fig. 2a, Moving Image ). Due to the large thrombus burden, wiring of the circumflex ended up being a frustrating and cumbersome procedure even with balloon back-up (Fig. 2b). After successful placement of the wire in the distal circumflex, multiple attempts to manually aspirate and thereafter dilate the blood vessel with a compliant 4.0x20mm balloon failed to open the occluded artery (Fig. 2c and Moving Image  and ).
case_images: a. Second look angiography documented persistent occlusion of the circumflex artery. b. Injection through the microcatheter showed a completely thrombosed circumflex artery along its runoff. c. Manual aspiration and repeated balloon again failed to open the artery.
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case_images: F3
case_images: Twelve hours later, a second look angiography documented a persistent occlusion of the circumflex artery (Fig. 3a, Moving Image ). Moving Image ). Manual aspiration and repeated balloon dilatations with NC Quantum Maverick and Maverick balloon (Boston Scientific, 300 Boston Scientific Way Marlborough) again failed to open the artery (Fig. 3c, Moving Image ) At this point, a bolus dose of intracoronary Abciximab (ReoproR; Janssen-Cilag Zug, Schweiz) was administered distally through the FinecrossR and a continuous intra-venous perfusion was planned.
case_images: a and b. Coronary CT scan with i.v. contrast performed on the third day of admission, 48 hours after continuous administration of the glycoprotein IIb/IIIa inhibitor Abciximab documented a persistently occluded circumflex artery.
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case_images: F4
case_images: T2 weighted images confirmed myocardial edema (recent infarction).
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case_images: F5
case_images: T2 weighted images confirmed myocardial edema (recent infarction) (Fig. 5) as well as late gadolinium enhancement exposed transmural scarring (Fig. 6).