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Successful Emergency Coronary Artery Bypass Graft in a Patient With Hyperacute Stent Thrombosis and Cardiogenic Shock FREE TO VIEW

Ameer Rasheed, MD; Munsif Ali, MD; Viswanath Vasudevan, MD; Qammar Abbas, MD; Hafiz Imran, MD
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The Brooklyn Hospital Center, Brooklyn, NY

Chest. 2013;144(4_MeetingAbstracts):277A. doi:10.1378/chest.1704887
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SESSION TITLE: Critical Care Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Coronary artery stent thrombosis is a rare complication and leads to ST elevation myocardial infarction or sudden cardiac death. Simultaneous multivessel stent thrombosis is very rare and can have catastrophic results. We present a unique case of cardiogenic shock resulting from in stent thrombosis within few minutes of stent deployment. Our patient underwent successful emergency coronary bypass.

CASE PRESENTATION: A 56 years old previously healthy gentleman presented with chest pain. Physical examination was within normal limits. Complete blood count and serum biochemistry were normal. EKG showed ST segment elevation. Coronary Angiography with successful PCI with a stent to RCA and LAD was performed. Patient was discharged home with ASA and Clopidogrel. Next day he presented with recurrent chest pain. EKG again showed ST segment elevations in inferior leads. Coronary angiography showed in stent thrombosis in both stents. Successful PCI was performed with 2 stents to LAD and 2 stents to RCA with final TIMI 3 distal flow without residual stenosis or dissection at both coronary arteries. While waiting in recovery room patient started to have chest pain and EKG showed increasing ST segment elevations. Emergent repeat angiography showed significant simultaneous near complete occlusion of all four stents. Soon he developed cardiogenic shock. Emergent Coronary Artery Bypass Graft Surgery was performed. He had meaningful recovery with resolution of acute kidney injury and shock liver.

DISCUSSION: Most cases of stent thrombosis occur within the first month after deployment, irrespective of the stent type. To the best of our knowledge this is the first case report of simultaneous hyperacute thrombosis of four stents in two separate coronary arteries within few minutes of stent placement. Diabetes mellitus, left ventricular dysfunction, prior brachytherapy, malignancy, chronic kidney disease, hypercoagulable state and poor compliance to medications have been documented in literature but our patient had none of these risk factors. Periprocedural coronary dissection or stent malposition was not considered because the patient’s repeat catheterization did not reveal any dissection. In our patient stent thrombosis was likely due to oxidative stress, systemic inflammatory and thrombogenic milieu due to acute coronary syndromes, or secondary thrombosis due to systemic hypotension after one stent thrombosis.

CONCLUSIONS: Hyperacure in stent thrombosis is rarity and has not been described in literature. It may present as cardiogenic shock. Exact etiology is unknown but it could be secondary to thrombosis due to hypotension. Emergent CABG has a better outcome than re-stenting. More studies are needed to understand molecular and biochemical nature of hyperacute thrombosis.

Reference #1: Mauri L, Hsieh WH, Massaro JM, Ho KK, D’Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med, 2007; 356: 1020-1029.

DISCLOSURE: The following authors have nothing to disclose: Ameer Rasheed, Munsif Ali, Viswanath Vasudevan, Qammar Abbas, Hafiz Imran

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