Distal Artery Occlusion Research Articles

Direct Microsurgical Embolectomy for an Acute Distal Basilar Artery Occlusion

Acute basilar artery occlusion is associated with high mortality rates, up to 35%-40%. Early revascularization by intravenous thrombolysis, intra-arterial thrombolysis, and endovascular mechanical embolectomy is considered the best option to date. The objective of this technical report is to present the direct microsurgical embolectomy technique for an acute distal basilar artery occlusion as an urgent life-saving revascularization procedure. A 71-year-old male patient suffered from an acute embolic basilar artery occlusion and became unconscious (Glasgow Coma Scale 4). Computed tomography angiography and MRA revealed the distal basilar artery occlusion along with an increased diffusion-weighted imaging signal in the corresponding territory. After an individual case discussion, the patient underwent a microsurgical embolectomy via a frontotemporal craniotomy and an anterior temporal approach. Intraoperative indocyanine green and postoperative computed tomography angiography revealed complete revascularization of the previously occluded basilar quadfurcation. The patient steadily recovered and was able to walk with assistance after 4 weeks. Microsurgical embolectomy can be an effective treatment option for acute distal basilar artery occlusion in selected cases with experienced surgeons, but a critical preoperative decision-making process is needed.

Methodological issues for designing and conducting a multicenter, international clinical trial in Acute Stroke: Experience from ARTSS-2 trial

BackgroundWe describe innovations in the study design and the efficient data coordination of a randomized multicenter trial of Argatroban in Combination with Recombinant Tissue Plasminogen Activator for Acute Stroke (ARTSS-2). MethodsARTSS-2 is a 3-arm, multisite/multiregional randomized controlled trials (RCTs) of two doses of Argatroban injection (low, high) in combination with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke patients and rt-PA alone. We developed a covariate adaptive randomization program that balanced the study arms with respect to study site as well as hemorrhage after thrombolysis (HAT) score and presence of distal internal carotid artery occlusion (DICAO). We used simulation studies to validate performance of the randomization program before making any adaptations during the trial. For the first 90 patients enrolled in ARTSS-2, we evaluated performance of our randomization program using chi-square tests of homogeneity or extended Fisher's exact test. We also designed a four-step partly Bayesian safety stopping rule for low and high dose Argatroban arms. ResultsHomogeneity of the study arms was confirmed with respect to distribution of study site (UK sites vs. US sites, P=0.98), HAT score (0–2 vs. 3–5, P=1.0), and DICAO (N/A vs. No vs. Yes, P=0.97). Our stopping thresholds for safety of low and high dose Argatroban were not crossed. Despite challenges, data quality was assured. ConclusionsWe recommend adaptive designs for randomization and Bayesian safety stopping rules for multisite Phase I/II RCTs for maintaining additional flexibility. Efficient data coordination could lead to improved data quality.

Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.

Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort. Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%). The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90). Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.

Abstract W P12: Baseline Predictors of the Malignant Collateral Profile in IMS III

Background: Collateral circulation has repeatedly been cited as a decisive factor in successful angiographic and clinical outcomes after endovascular therapy, offering rational selection criteria. Identifying patients with a malignant collateral profile, portending poor outcome, would greatly enhance decision-making in acute stroke. We analyzed the IMS III dataset to delineate baseline predictors of poor angiographic collaterals. Methods: Collateral grade was prospectively evaluated by the angiography core lab in IMS III. Poor collaterals or a malignant collateral profile was defined as ASITN grade 0-1. Baseline clinical, laboratory and non-contrast CT variables were evaluated in univariate and multivariable logistic regression as predictors of the malignant collateral profile. Results: 278 patients (mean age 65.3±12.6 years, 54% women, median NIHSS 17 (IQR 13-20) had collateral grading assessed at angiography. Malignant collaterals (ASITN 0-1) were noted in 77/278 (28%). Univariate analyses revealed that only history of HTN (88.3 vs. 71.0%, p=0.004), CHF (17.6 vs.8.0%, p=0.040), admission DBP (89±24 vs. 81±17 (mm Hg, mean±SD), p=0.002), NIHSS>19 (40.3 vs. 28.4%, p=0.080), distal arterial occlusion location (p=0.002) and ASPECTS 0-4 (24.7 vs. 9.4%, p=0.002) were associated with malignant collaterals. Time from stroke onset to angiography was unrelated to collateral grade. Predictors in multivariable analyses included ASPECTS 0-4 (OR 3.72, 95%CI (1.60-8.66), p=0.002), HTN (OR 2.33, 95%CI (1.01-5.38), p=0.047), NIHSS>19 (OR 2.26, 95%CI (1.16-4.40), p=0.017), distal arterial occlusion (OR 2.08, 95%CI (1.43-3.04), p<0.001) and higher admission DBP (OR 1.02 per mm Hg, 95%CI (1.00-1.03), p=0.035). When ASPECTS 5-10, only NIHSS>19 (OR 2.81, 95%CI (1.35-5.86), p=0.006) and distal arterial occlusion (OR 2.58, 95%CI (1.70-3.92), p<0.001) predicted malignant collaterals. Conclusions: Elevated diastolic blood pressure, history of hypertension, NIHSS>19, lower ASPECTS and distal arterial occlusion are strong predictors of the malignant collateral profile. Future studies should validate and implement a concomitant risk score for triage of acute stroke patients.

The Allen's test: Revisiting the importance of bidirectional testing to determine candidacy and design of radial forearm free flap harvest in the era of trans radial endovascular access procedures

BackgroundThe radial forearm free flap is a workhorse free flap. The radial artery, which supplies it, is increasingly being used for endovascular access. A complication of this is radial artery occlusion. Although often asymptomatic it can compromise future free tissue transfer.Case PresentationTwo patients who underwent RFFF harvest for head and neck reconstruction are presented; both of who likely had distal radial artery occlusion.The first patient had failure of flap perfusion, presumed secondary to radial artery occlusion from prior endovascular access at the distal radial artery. In the second case, we used the Allen’s test in reverse to identify the same scenario and successfully redesigned the harvest.ConclusionThe Allen’s test is a simple bedside test that should be performed bidirectionally to exclude radial artery occlusion, which may compromise flap harvest. Radial artery occlusion will become increasingly common as the radial artery is used more frequently for endovascular access procedures.

GW25-e3443 Novel therapy for Distal Extremity Artery Occlusion by Argatroban Combined with Alprostadil

Distal extremity arterial occlusion is common among peripheral arterial disease (PAD), which is alone or combined with proximal extremity arterial lesion, particularly in elder and terminal renal disease or diabetes patients. However, poor prospective results, even impossibility are from angioplasty

Predictors of Outcome following Stroke due to Isolated M2 Occlusions

Background: Factors influencing outcome after cerebral artery occlusion are not completely understood. Although it is well accepted that the site of arterial occlusion critically influences outcome, the majority of studies investigating this issue has focused on proximal large artery occlusion. To gain a better understanding of factors influencing outcome after distal large artery occlusion, we sought to assess predictors of outcome following isolated M2 middle cerebral artery occlusion infarcts. Methods: We retrospectively analyzed patients with isolated acute M2 occlusion admitted to a single academic center from January 2010 to August 2012. Baseline clinical, laboratory imaging, and outcome data were assessed from a prospectively collected database. Factors associated with a modified Rankin Scale (mRS) score ≤2 in univariable analyses (p < 0.05) were entered into multivariable logistic regression analysis. The Admission National Institutes of Health Stroke Scale (aNIHSS) score, age, and infarct volume were also entered as dichotomized variables. Receiver operating characteristic curves were plotted to determine the optimal aNIHSS score, infarct volume, and age cut points predicting an mRS score ≤2. Optimal thresholds were determined by maximizing the Youden index. Respective multivariable logistic regression analyses were used to identify independent predictors of a good 90-day outcome (mRS score ≤2; primary analysis) as well as 90-day mortality (secondary outcome). Results: 90 patients with isolated M2 occlusion were included in the final analyses. Of these, 69% had a good 90-day outcome which was associated with age <80 years (p = 0.007), aNIHSS <10 (p = 0.002), and infarct volume ≤26 ml (p < 0.001). Notably, 20% of patients (64% of those with a poor outcome) had died by 90 days. Secondary analysis for 90-day mortality was performed. This analysis indicated that infarct volume >28 ml (OR 11.874, 95% CI 2.630-53.604, p = 0.001), age >80 years (OR 4.953, 95% CI 1.087-22.563, p = 0.039), need for intubation (OR 7.788, 95% CI 1.072-56.604), and history of congestive heart failure (OR 5.819, 95% CI 1.140-29.695) were independent predictors of 90-day mortality (20% of all included patients). Conclusion: While the majority of patients with isolated M2 occlusion stroke has a good 90-day outcome, a substantial proportion of subjects dies by 90 days, as identified by a unique subset of predictors. The knowledge gained from our study may lead to an improvement in the prognostic accuracy, clinical management, and resource utilization in this patient population.

Acute ascending thrombosis of abdominal and suprarenal aorta.

We report the diagnostic and successful therapeutic images of an acute occlusion of the abdominal and suprarenal aorta. This lesion is a rare but catastrophic pathology which can cause severe ischemic manifestations, depending on the site of obstruction, with high rate of mortality even after treatment. In the majority of cases it represents a surgical emergency. Although the mechanism of the thrombosis has not been delineated, the proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, dislodgment of a mural thrombus, or coagulation disorders. Frequent risk factors include advanced atherosclerosis combined with a low flow state because of poor cardiac performance. The management of this condition includes immediate intervention with systemic heparinization, improvement of the cardiac condition, and surgical revascularization based on the clinical and anatomical presentation. In this case the authors highlight the importance of an early detection and early intervention to enhance survival rates and reduce morbidity.

Acute Ischemic Stroke in a 12-Year-Old Successfully Treated With Mechanical Thrombectomy

We report the case of a healthy 12-year-old girl with an acute ischemic stroke successfully treated with mechanical thrombectomy. The child was referred to our hospital 6 hours after sudden onset of severe headache and left hemiparesis. Cerebral angiography findings were consistent with right distal internal carotid artery occlusion in addition to ipsilateral middle cerebral artery occlusion. Subsequent mechanical thrombectomy with Solitaire AB device resulted in complete vessel recanalization. The patient experienced progressive neurologic improvement with good clinical recovery at the 3-month follow-up. To our knowledge, only 3 cases of primary mechanical thrombectomy in children have been previously reported in the literature. Safety and efficacy data for endovascular therapies in pediatric acute ischemic stroke are lacking. We propose mechanical thrombectomy as an option in children with significant neurologic deficits and proven arterial occlusion, especially when the therapeutic window for intravenous thrombolysis has been exceeded.

Endovascular Treatment of Distal Internal Carotid Artery Occlusions with Retrievable Stents

Background: Acute stroke due to distal intracranial internal carotid artery (ICA) occlusion has a poor natural history. Outcome in patients who receive intravenous tissue plasminogen activator (tPA) is also unsatisfactory. The objective of this study is to evaluate the effectiveness and safety of endovascular treatment with retrievable stents in these patients. Methods: Data from a prospective register of patients with acute stroke treated with an endovascular procedure in a single centre were analysed. Results: A total of 20 patients with distal ICA occlusion were collected. Mean baseline National Institutes of Health Stroke Scale score was 18. Eight cases (40%) had received previous intravenous tPA. Mean time from stroke to recanalization was 393 min. Retrievable stents with proximal occlusion and aspiration were used in all cases. In 3 patients, 2 retrievable stents were used simultaneously. Complete recanalization (thrombolysis in cerebral infarction 2b/3) was accomplished in 85% of cases. A favourable clinical outcome (modified Rankin Scale score 0-2) was achieved in 13 patients (65%). Mortality occurred in 2 cases (10%). Conclusions: Endovascular treatment of patients with distal ICA occlusion seems safe and effective. Retrievable stents may be the treatment of choice, although randomized clinical trials are necessary. The use of 2 retrievable stents at the same time could be an alternative technique useful in thrombi of larger size.

Endovascular Revascularization in Secondary Raynaud's Phenomenon

Endovascular intervention is not previously described in patients with exacerbated Raynaud ’ s phenomenon (RP). A 45-year-old male with secondary RP and CREST (Calcinosis cutis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia) with a smoking history, who was noncompliant in the non-interventional treatment, presented with necrosis of the right hand in exacerbated RP. An intra-arterial digital subtraction angiography (DSA) showed occlusion of the right distal ulnar and radial arteries. Initial pharmacological therapy showed no improvement. Thrombolysis with Urokinase therapy had a beneficial, but not optimal, effect on perfusion. This was probably due to an atherosclerotic component. An endovascular intervention, 2 mm balloon dilatation, in the right radial artery; improved this significantly. The clinical situation proved stable and no expansion of necrosis was seen. An endovascular procedure, not previously described in RP management, can be helpful in the treatment of exacerbated RP; especially when an atherosclerotic component is present. doi: http://dx.doi.org/10.4021/jmc478 w

A Myth Debunked: the Results of SYNTHESIS Expansion and IMS III

A Myth Debunked: the Results of SYNTHESIS Expansion and IMS III

Endovascular Revascularization in Secondary Raynaud’s Phenomenon

Endovascular intervention is not previously described in patients with exacerbated Raynaud’s phenomenon (RP). A 45-year-old male with secondary RP and CREST (Calcinosis cutis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia) with a smoking history, who was noncompliant in the non-interventional treatment, presented with necrosis of the right hand in exacerbated RP. An intra-arterial digital subtraction angiography (DSA) showed occlusion of the right distal ulnar and radial arteries. Initial pharmacological therapy showed no improvement. Thrombolysis with Urokinase therapy had a beneficial, but not optimal, effect on perfusion. This was probably due to an atherosclerotic component. An endovascular intervention, 2 mm balloon dilatation, in the right radial artery; improved this significantly. The clinical situation proved stable and no expansion of necrosis was seen. An endovascular procedure, not previously described in RP management, can be helpful in the treatment of exacerbated RP; especially when an atherosclerotic component is present. J Med Cases. 2013;4(3):185-188 doi: https://doi.org/10.4021/jmc478w

Mechanical thrombectomy using Rotarex system and stent-in-stent placement for treatment of distal femoral artery occlusion secondary to stent fracture – a case report and literature review

SummaryBackground:Treatment of peripheral arterial diseases may be distinguished into conservative and interventional management; the latter is divided into surgical and endovascular procedures. Management of peripheral artery stenosis and occlusion with vascular stents is associated with the risk of late complications such as restenosis, stent fracture or dislocation.Case Report:A 62-year-old woman with generalized atherosclerosis, particularly extensive in lower limb arteries, was admitted to the Department of Angiology 11 months after having an endovascular procedure performed due to critical ischemia of left lower limb. Because of stent occlusion, a decision to perform angiographic examination of lower limb arteries was made. Examination revealed occlusion of the superficial femoral artery along its entire length, including previously implanted stents. Distal stent was fractured with slight dislocation of the proximal segment. A decision was made to perform mechanical thrombectomy using a Rotarex system followed by a stent-in-stent placement procedure. Follow-up angiography and ultrasound scan performed 24 hours after the procedure revealed a patent vessel with satisfactory blood flow.Discussion:Nowadays, imaging diagnostics of peripheral artery stenosis involves non-invasive examinations such as ultrasound, minimally invasive examinations such as angio-MRI and MDCT, or invasive examinations such as DSA and IVUS. DSA examinations are used to confirm significant stenosis or occlusion of a vessel, particularly when qualifying a patient for endovascular treatment. Due to their anatomic location, the superficial femoral artery and the popliteal artery are subject to various forces e.g. those exerted by the working muscles. Mechanical thrombectomy and atherectomy are efficient methods of arterial recanalization used in the treatment of acute, subacute or even chronic occlusions or stenosis of peripheral vessels.Conclusions:Frequency of angioplasty and vascular stent implantation procedures is increased in patients with peripheral arterial disease, thus increasing the incidence of reported early and late complications such as acute stent thrombosis, restenosis and stent fractures. The Rotarex transcutaneous mechanical thrombectomy system is an efficient method of treating occlusions in arterial stents. It is also safe when performed by experienced operators.

Distal Subclavian Artery Occlusion Causing Multiple Cerebral Infarcts Consequence of Retrograde Flow of a Thrombus?

Intracranial embolization usually arises from the heart, a vertebrobasilar artery, a carotid artery, or the aorta, but rarely from the distal subclavian artery upstream of an embolus. We report on a patient who experienced left shoulder and forearm pain with weak blood pressure and pulse followed by concurrent onset of left hemiplegia. This case is a rare example of multiple cerebral embolic infarctions, which developed as a complication of distal subclavian artery thrombosis possibly associated with protein S deficiency.

Impact of Collateral Circulation on Early Outcome and Risk of Hemorrhagic Complications after Systemic Thrombolysis

In stroke patients, collateral flow can rapidly be assessed on computed tomography angiography (CTA). In this study, the impact of baseline collaterals on early outcome and risk of symptomatic intracerebral hemorrhages after systemic thrombolysis in patients with proximal arterial occlusions within the anterior circulation were analyzed. Collateralization scores were determined on the CT angiography source images (0 = absent; 1 ≤ 50%, 2 > 50% but <100%, and 3 = 100% collateral filling) of patients with distal intracranial carotid artery and/or M1 segment occlusions treated from 2008 to December 2011. A collateral score of 0 to 1 was designated as poor and 2 to 3 as good collateral vessel status. Outcome variables included in hospital mortality, favorable outcome at discharge (modified Rankin score ≤ 2), and rates of symptomatic intracerebral hemorrhage based on the European-Australasian Acute Stroke Study II definition. Among 246 subjects (mean age of 74 years; median National Institutes of Health Stroke Scale N at admission 14), 205 patients (83%) had good collaterals, whereas 41 patients (17%) had poor collaterals, respectively. Patients with poor collaterals had significantly higher rates of in-hospital mortality (41% vs. 12%, P < 0·001), of symptomatic intracerebral hemorrhage (15% vs. 4·9%, P < 0·05) and had significantly lower rates of favorable early clinical outcome (0% vs. 28%, P < 0·001) compared with those with good collaterals. The grade of collateralization was independently associated with in-hospital mortality (P < 0·001), early clinical outcome (P < 0·01), and rates of symptomatic intracerebral hemorrhage (P < 0·01). Patients with proximal arterial occlusions within the anterior circulation and poor baseline collaterals have a poor early functional outcome and high rates of symptomatic intracerebral hemorrhage after systemic thrombolysis. Since similar findings have also been reported after endovascular therapy, strategies to improve collateral blood flow should be assessed in this patient population.

Fragmental or Massive Embolization in Cardiogenic Stroke Caused by Nonvalvular Atrial Fibrillation

After cardioembolic stroke (CES), left atrial thrombus (LAT) is detected by transesophageal echocardiography (TEE) in some cases but not in others. We propose that there are 2 types of embolization in CES: fragmental and massive embolization. Consecutive patients with nonvalvular atrial fibrillation (AF) of acute CES or transient ischemic attack (TIA) were prospectively enrolled in the study between May 2009 and July 2011. TEE was performed within 7 days of admission. The patients were classified into 2 groups: those with occlusion of the main trunk (internal carotid artery, M1, and basilar artery; group M) and those with occlusion of other distal arteries (group D). Clinical features were compared between patients who did and did not have a thrombus on TEE. Of the 41 patients in the study, 21 were in group M and 20 were in group D. Age, sex, and treatment with tissue plasminogen activator did not differ significantly between the 2 groups. The rate of detection of LAT was significantly higher in group D (14% v 65%; P<.001). Patients with distal artery occlusion had a significantly higher rate of LAT compared to those with main trunk occlusion. Distal artery occlusion inCES therefore tends to result from fragmental embolization and is associated with a remnant LAT, with which there may be a concern of a risk of early recurrence.

A Systematic Review of the Outcomes of Distal Upper Extremity Bypass Surgery With Arterial and Venous Conduits

To conduct a systematic review of literature evaluating efficacy of venous and arterial grafts for distal upper extremity bypass surgery. A PubMed search using MeSH terms "veins/surgery" OR "arteries/surgery" AND "radial artery/surgery" OR "ulnar artery/surgery" yielded 794 studies. Manual review produced 42 studies based on inclusion criteria of reported distal upper extremity bypass surgery, complete information on graft type used, examined patency of reconstruction, and described method for determining patency. Studies meeting inclusion criteria underwent data extraction focusing on demographics, revascularization site, conduit type, microsurgical technique, subjective/objective outcomes, and postoperative anticoagulation regimens. Sixteen studies met the inclusion criteria. In 145 patients, 152 grafts were performed for upper extremity revascularization, including 120 grafts for revascularization of distal ulnar artery circulation, 31 for distal radial artery circulation, and 1 for both distal ulnar and radial artery occlusions. Overall patency rate was 87% at an average follow-up of 34 months. Of 152 bypass grafts, 19 were arterial conduits. Donor sites included the deep inferior epigastric artery, subscapular artery, thoracodorsal artery, and descending branch of the lateral femoral circumflex artery. At a mean follow-up of 18 months, arterial conduit patency was 100%. The remaining 133 bypass procedures used vein grafts from various donor sites, including the saphenous, cephalic, and basilic veins. At an average follow-up of 37 months, overall vein graft patency rate was 85%. There was a statistically significant difference between patency rates of arterial conduits compared with venous conduits. All studies reported improved ischemic symptoms including reduction of cold sensitivity, pain, and digital ulceration. This review showed a high patency rate and clinical efficacy of distal upper extremity bypass surgery with a mean follow-up of almost 3 years. There may be a benefit of using arterial versus venous conduits, although further examination is needed given the small number of arterial reconstructions reported.

Isolated right coronary lesion and anterolateral papillary muscle rupture - case report and review of the literature

Ischemic rupture of the anterolateral papillary muscle is uncommon due to its dual blood supply. It usually follows an ischemic event involving branches of the left circumflex or left anterior descending arteries. We present a case of a patient admitted with an acute inferior wall myocardial infarction and an isolated distal right coronary artery occlusion. Acute mitral regurgitation with rupture of the anterolateral papillary muscle was diagnosed on the fifth post-infarction day. The patient underwent mitral valve replacement and coronary artery bypass grafting to the posterior descending artery. We conclude that anterolateral papillary muscle rupture may also result from an isolated right coronary lesion.

Value of ST Segment Changes in 12 Lead ECG to Detect Proximal Versus Distal Right Coronary Artery Occlusion in Acute Inferoposterior Myocardial Infarction

Background: A history of ischemic-type discomfort &amp; the initial 12- lead ECG are the primary tools for screening patients with acute myocardial infarction in the emergency department. ST elevation in inferior leads indicates an evolving myocardial infarction of the inferoposterior wall. The outcome of patients with inferoposterior myocardial infarction due to occlusion of right coronary artery depends mainly on the location of occlusion (distal versus proximal). Hypothesis: Value of ST-segment depression in lateral leads (I and aVL) and ST-segment changes in lead V1 to predict the site of right coronary artery occlusion in the case of an inferoposterior myocardial infarction. Objective: To predict the site of right coronary artery (RCA) occlusion ( proximal or distal) in acute inferoposterior myocardial infarction by ST segment depression in leads 1 &amp; aVL and ST-segment changes( is electric/ elevated or depressed) in V1.Methods and Results: A total of fifty four patients of ST-segment elevation inferoposterior wall AMI due to suspected RCA occlusion, admitted within 12 hours of onset of chest pain, and subsequently underwent coronary angiography during hospitalization, were selected for the study. Patients were divided into two groups on the basis of angiographic findings: proximal RCA occlusion (group I) and distal RCA occlusion (group II). A 12 lead ECG was taken on admission. ST segment deviation in lateral leads (I &amp; aVL) as well as in precordial lead (V1) was calculated. Isoelectric or elevated ST-segment in V1 predicted proximal RCA occlusion whereas depressed ST-segment predicted distal RCA occlusion. It was demonstrated that, STsegment changes in precordial lead (V1) was a sensitive &amp; specific marker to discriminate proximal &amp; distal RCA occlusion in inferoposterior wall AMI with high positive &amp; negative predictive value, but ST-segment changes in lateral leads (I &amp; aVL) although more specific for proximal RCA occlusion did not seem to be of clinical value due to its low sensitivity. DOI: http://dx.doi.org/10.3329/uhj.v7i2.10844 University Heart. Journal Vol. 7, No. 2, July 2011