Distal embolization is an acute complication of percutaneous coronary intervention (PCI). Distal embolization ofplaque and thrombus material is considered as a major cause of insufficient reperfusion despite a fully patent infarctrelatedartery, apart from ischemic microvascular damage and reperfusion-induced regional inflammatory responses.In a recent study, angiographic evidence of distal embolization was associated with an 8-fold increase in 5-yearmortality.We reported on our experience with distal embolization durante PCI which lead the patient developed STElevationMyocardial Infarct (STEMI) inferior and posterior accompanied with severe chest pain and was treated inthe Intesive Coronary Care Unit (ICCU). Distal embolization is the case that we should be put into our awarenessbecause it can worse the after procedural outcome.Key words: distal embolization-percutaneous coronary intervention-insufficient reperfusion- myocardial ischemiaangiographi

Betty Dwi Lestari, Budi Yuli Setianto

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Journal of the Medical Sciences (Berkala ilmu Kedokteran)

51Setianto & Lestari, Distal embolization durante percutaneous coronary interventionDistal embolization durante percutaneouscoronary intervention: a case reportBudi Yuli Setianto1*, Betty Dwi Lestari21 Department of Cardiology, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito Hospital Yogyakarta2 Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito Hospital YogyakartaABSTRACTDistal embolization is an acute complication of percutaneous coronary intervention (PCI). Distal embolization ofplaque and thrombus material is considered as a major cause of insufficient reperfusion despite a fully patent infarct-related artery, apart from ischemic microvascular damage and reperfusion-induced regional inflammatory responses.In a recent study, angiographic evidence of distal embolization was associated with an 8-fold increase in 5-yearmortality. We reported on our experience with distal embolization durante PCI which lead the patient developed ST-Elevation Myocardial Infarct (STEMI) inferior and posterior accompanied with severe chest pain and was treated inthe Intesive Coronary Care Unit (ICCU). Distal embolization is the case that we should be put into our awarenessbecause it can worse the after procedural outcome.Key words: distal embolization-percutaneous coronary intervention-insufficient reperfusion- myocardial ischemia-angiographic* Corresponding author : budyyuls@gmail.comINTRODUCTIONDistal embolization is defined as an abrupt cut-off in the main vessel or one of the coronarybranches of the infarct-related artery, distal to theangioplasty site.1Downstream embolization can bein the form of thrombus and/or plaque contents(atheroma) with vascular obstruction is commonafter PCI.2 Angiographic evidence of distalembolization is found in 9% to 15% of the patientsafter primary PCI for acute myocardial infarction,but the true incidence of distal embolization may beconsiderably higher, as suggested by autopsy studiesand experience with distal protection devices. Distalembolization appears to have major impact on long-term clinical outcome after primary PCI.3Myocardial ischemia can result from anyof the coronary artery complications and can leadto variety of complications either during or afterPCI, including chest pain, ST elevation myocardialinfact (STEMI), cardiac enzyme elevation, andmyocardial stunning.2We reported on our experiencewith distal embolization durante PCI which lead thepatient developed STEMI inferior and posterior.CASE REPORTA 51 year-old male with diabetes, hypertensionand hypercholesterolemia presented with non-ST-elevation myocardial infarction (NSTEMI). Hiscoronary angiogram showed 90% stenosis in mid-and 80% stenosis in distal part of right coronaryartery (RCA) and 40% left anterior descendent(LAD) artery (FIGURE 1).The PCI procedure revealed, 80% stenosis indistal part of right coronary artery (RCA) was dilatedwith Voyager 30/15 ballon (FIGURE 2) and 90%stenosis in mid of part of RCA treated direct stentwith Coroflex Please 4.0/16 but unsuccessful,showed an acute closure in distal part of RCA(FIGURE 3 and 4).J Med SciVolume 43, No. 1, March 2011: 51-5552J Med Sci, Volume 43, No. 1, March 2011: 51-55FIGURE 1. 80% and 90% stenosis in RCA FIGURE 2. Predilatation RCA distalFIGURE 3. Direct stent RCA mid FIGURE 4. Acute clossureThe lesion was dilatated by voyager 30/15balloon and showed TIMI-2 (Thrombolysis inMyocardial Infarction trial)-2 flow (FIGURE 5).After predilatation, Tsunami Gold 4.0/20 stent wasdeployed across the lesion. The angiogram showed0 percent residual but still had TIMI-2 flow becausethere was a distal embolization (FIGURE 6).53Setianto & Lestari, Distal embolization durante percutaneous coronary interventionFIGURE 5. Distal embolization in bifucartion FIGURE 6. Final result TIMI-2 flow after stent deployedThe patient suffered typical chest pain afterPCI with the electrocardiogram (ECG) showedSTEMI inferior and posterior. The cardiac enzymeswere elevated, glutamic oxaloacetic transaminase(GOT) from 24 u/L to 471 u/L, lactate dehydro-genase 1788 u/L, creatine kinase – MB isoform(CK-MB) 237.1 u/L, and troponin I more than 22.78ng/mL. The patient was treated in ICCU withtirofiban (Aggrastat®) 0.15mcg/kg/hour continuedwith unfractionated heparin (UFH), acetylsalicylicacid 160 mg twice a day, clopidogrel 75 mg once aday, isosorbide dinitrate 5mg three times a day,atorvastatine 10mg once a day, amlodipine 5mg oncea day, fenofibrate 200 mg once a day, ramipril 5mgonce a day, and sliding scale to control blood sugar.The third day in ICCU, patient suffered severechest pain followed with bradycardia. The patientwas treated with cervical epidural block combinationchirocaine 0.125 mg and morfine 0.125 mg everyeight hour. The patient had no chest pain in ninthday and allowed to discharge from hospital.DISCUSSIONPercutaneous transluminal coronary angioplasty(PTCA) was associated with two major limitations:acute (during the procedure) or subacute (after theprocedure and within 30 days) vessel closure; andlate (four to eight months postprocedure)thrombosis. The availability of intracoronary stents(PCI) and the ongoing improvements in stent design,technique, and antithrombotic therapy have resultedin significant reductions in both of thesecomplications.Acute closure has been reduced from2 to 10 % with PTCA alone to <1 % in the stentera. The rate of subacute thrombosis has fallen from5 % with PTCA alone to about 0.5 to 1.0 % withstents. Restenosis rates have fallen from 30 to 40% after balloon angioplasty to 20 to 30 % after baremetal stents to less than 10 % with drug-elutingstents.4 Complications associated with PCI aresimilar to those resulting from diagnostic cardiaccatheterization, but their prevalence is morefrequent. Complications have been categorized asmajor (death, myocardial infarct (MI), and stroke)or minor (transient ischemic attack, access sitecomplications, renal insufficiency, or adversereactions to radiographic contrast). Additionalspecific complications include intracoronarythrombosis, coronary perforation, tamponade, andarrhythmias.5Distal embolism of thrombus and plaque debriscaused by percutaneous coronary intervention (PCI)has been regarded as a cause of microcirculationimpairment. Distal embolization of plaque debris wasdetected more frequently in patients with rupturedplaque. Microcirculation damage and left ventricular54J Med Sci, Volume 43, No. 1, March 2011: 51-55dysfunction are increased mainly by distalembolization of plaque debris rather than ofthrombus.6Distal embolization can contribute to the “no-reflow” phenomenon after PCI. No-reflow is thoughtto reflect microvascular dysfunction since there isevidence of myocardial ischemia and reducedantegrade coronary flow in the absence of epicardialstenosis or loss of a distal branch. In a report ofpatients undergoing PCI for a Non-ST-ElevationMyocardial Infarct (NSTEMI), those with apostprocedural troponin I elevation were significantlymore likely to have reduced tissue-level perfusionthan those without a troponin I elevation.2Anatomical (or angiographic) success afterPCI is defined as the attainment of residual diameterstenosis less than 50 %, which is generally associatedwith at least 20 % improvement in diameter stenosisand relief of ischemia. With the widespread use ofcoronary stent, the angiographic criterion for successis 20 % stenosis or less when stent is used.Procedural success is defined as angiographicsuccess without the occurrence of majorcomplications (death, MI or coronary artery bypassgraft (CABG) surgery) within 30 days of theprocedure. Clinical success is defined as proceduralsuccess without the need for urgent repeat PCI orsurgical revascularization within the first 30 days ofthe procedure.7Procedural success (TIMI 3 flow) and perfusion(blush score) were reduced with distal embolizationand associated with larger infark size, lower ejectionfraction, and substantially higher 5-year mortality.8No-reflow is likely caused by distal embolization ofatheromatous and thrombotic debris dislodged byballoon inflation or stent implantation. No-reflow isdefined as reduced anterograde perfusion in theabsence of flow-limitation stenosis, and occurs inup to 2 to 3 % of PCI procedure.7The diabetic patients tend to have more distalembolization compare with nondiabetic patients andit is associated with a significantly higher mortality.Review study on 1662 patients undergoing primaryangioplasty for STEMI included in 11 randomizedtrials. Diabetes was observed in a total of 281patients (16.9%). Diabetic patients were older, witha larger prevalence of female gender, hypertension,hypercholesterolemia, advanced killip class atpresentation and multivessel disease. Diabetes wasassociated with significant impaired postproceduralTIMI-3 flow, myocardial blush grade (MBG) 2-3,complete ST-segment resolution and more distalembolization. The association with impaired MBGand distal embolization was confirmed aftercorrection for baseline confounding factors. Thisstudy showed that, among patients with STEMIundergoing primary angioplasty on the top ofglycoprotein IIb-IIIa inhibitors, diabetes mellitus wasindependently associated with impaired perfusionand distal embolization, that contribute to explainthe higher mortality observed in these patients.1Diabetes is the risk factors for a final TIMIflow grade 2 after primary PCI. The other riskfactors are age 70 years, longer time toreperfusion, initial TIMI flow grade d” 1, leftventricular ejection fraction <50 percent.9 Patientwho do not achieve TIMI 3 (normal) flow afterprimary PCI have worse outcomes. The PrimaryAngioplasty in Myocardial Infarction (PAMI) trialsreported patients who had a final TIMI flow grade2 after PCI had significantly higher rates of in-hospital mortality, and in-hospital major adversecardiac events than those with TIMI 3 flow. At oneyear, significant differences persisted for mortality,major adverse cardiac events, and reinfarction.9CONCLUSIONA case of distal embolization durante PCI hasbeen reported. The direct stenting failed and showedacute closure and distal embolization. The patientsuffered severe chest pain and the ECG showedST-elevation MI inferior and posterior. Distalembolization is an acute complication in PCI. Wehave to be aware of the possibility thrombus and/orplaque debris embolization. Study about distalprotection device and intracoronary antithromboticto prevent distal embolization are stil ongoing.ACKNOWLEDGMENTAuthors would like to thank Director and Staffof Cardiology Department of Dr. Sardjito GeneralHospital for permission and assistance to conductthis study.55Setianto & Lestari, Distal embolization durante percutaneous coronary interventionREFERENCES1. De Luca G, Gibson CM, Bellandi F, Noc M, Dudek D,Zeymer U, Arntz HR, Cutlip D, Maioli M, Zorman S,Mesquita GH, EmreA, Rakowski T, Gyongyosi M, HuberK, Van’t Hof AW. Diabetes mellitus is associated withdistal embolization, impaired myocardial perfusion, andhigher mortality in patients with ST-segment elevationmyocardial infarction treated with primary angioplasty andglycoprotein IIb-IIIa inhibitors.Atherosclerosis 2009; 207:181-5.2. Carrozza JP, Cutlip D, Levin T, Williams DO, SaperiaGM. Periprocedural complications of percutaneouscoronary intervention. [computer program] Up to date16.3. 20083. 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Distal embolization durante percutaneous coronary intervention: a case report

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Distal embolization durante percutaneous coronary intervention: a case report

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