Treatment of acute inferior wall myocardial infarction and ruptured abdominal aortic aneurysm: A hybrid approach

Abstract

A 64-year-old male patient was admitted to our emergency department with chest pain, profound hypotension and poor general condition. The initial electrocardiogram showed ST-segment elevation in leads DII, DIII and aVF with complete heart block. He was rapidly transferred to the catheterization laboratory for primary percutaneous intervention of the infarct-related artery. Initially, the right femoral artery was used for the arterial access site. During the advancement of the guide-wire, however, an unusual course apart from the route of the abdominal aorta was observed. The wire turned toward the right side of the patient at the level of the kidneys. Contrast injection demonstrated a huge aneurysmal dilation and slight blushing of the contrast agent at this level. The right radial artery was cannulated for the continuation of the procedure. Aortic root and proximal descending aortagraphy showed no aneurysm or dissection however, at the infra-renal level, previously detected huge aneurysmal dilation and slight blushing of the contrast agent were shown again (Movie 1). Meanwhile, a distal total occlusion of the right coronary artery was detected (Movie 2). Time-consuming left coronary system angiography was not performed. After emergent consultation with the department of cardiovascular surgery, a hybrid interventional procedure was decided. Accordingly, a direct bare-metal stent (4.0×12 mm) implantation to the right coronary artery was first performed with achievement of TIMI 3 flow and without administration of a thienopyridine drug or glycoprotein IIb/IIIa inhibitor agent (Movie 3). A single-dose of aspirin (300 mg) given in the emergency room and 5000 IU of unfractionated heparin were the only drugs administrated. After reperfusion, ST-segment resolution and sinus rhythm were obtained. The patient was then referred to operating room and standard aorta-bifemoral bypass surgery with a synthetic aortic Y-graft was applied for the treatment of ruptured abdominal aortic aneurysm. The oral thienopyridine drug, clopidogrel (75 mg/d), and aspirin (300 mg/d) were started after achieving hemostasis at the 3rd day postoperatively. Control angiography was performed at the 30th day postoperatively. Previously deployed stent was patent (Fig. 1a ) and no important stenosis was detected on the left coronary circulation. In addition, patent aorta-bifemoral Y-graft was demonstrated (Fig. 1b).