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Published on: November 24, 2014
Primary percutaneous coronary intervention without stenting using excimer laser and manual thrombectomy in STEMI with
Hirokazu Yokoi1, Takashi Yanagiuchi1, Shunpei Ushimaru1
1Department of Cardiology, Rakuwakai Otowa Hospital, 2 Otowa-chinji-cho, Yamashina-ku, Kyoto 607-8062, Japan.
Insights
In concurrent emergencies of ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation, prioritize PCI for STEMI. This case highlights laser angioplasty to avoid dual antiplatelet therapy (DAPT) in critical situations.
Area of Science:
- Cardiology
- Gastroenterology
- Emergency Medicine
Background:
- ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are critical medical emergencies.
- Concurrent presentation necessitates a clear treatment prioritization strategy.
Purpose of the Study:
- To present a case of concomitant STEMI and duodenal ulcer perforation.
- To discuss the optimal management sequence for these dual emergencies.
Main Methods:
- A patient with STEMI and duodenal ulcer perforation underwent immediate percutaneous coronary intervention (PCI) using excimer laser angioplasty and manual thrombectomy to avoid dual antiplatelet therapy (DAPT).
- The perforated ulcer was subsequently repaired surgically, followed by endoscopic hemostasis.
- A drug-coated stent was implanted during follow-up angiography.
Main Results:
- Successful PCI was achieved without immediate stenting, followed by surgical repair and endoscopic hemostasis.
- The patient was discharged with a favorable outcome.
- Delayed stenting was performed successfully after initial management.
Conclusions:
- Percutaneous coronary intervention (PCI) for STEMI should precede surgical repair of a perforated duodenal ulcer when STEMI poses an immediate life threat.
- Excimer laser coronary angioplasty with manual thrombectomy is a viable strategy to avoid dual antiplatelet therapy (DAPT) in complex cases.
- This approach facilitates subsequent definitive treatment for both conditions.
Background:
ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are both medical emergencies that require urgent intervention. In case that these time-sensitive medical emergencies present concomitantly, it remains unclear which one should be treated first.
Case Summary:
An 85-year-old man with melaena, epigastric pain, and severe anaemia was transferred to our emergency department and diagnosed as having inferior STEMI based on electrocardiogram. Emergency coronary angiography (CAG) revealed severe stenosis with thrombus in the proximal right coronary artery. Immediate oesophagogastroduodenoscopy and abdominal computed tomography detected the presence of duodenal ulcer perforation. Primary percutaneous coronary intervention (PCI) without stenting using excimer laser coronary angioplasty and manual thrombectomy was performed under intravascular ultrasound (IVUS) guidance to avoid dual antiplatelet therapy (DAPT). After successful PCI, the perforated viscus was surgically repaired with a laparoscopic omental patch. On Day 7, endoscopic haemostasis treated the oozing of blood from the duodenal ulcer. On Day 21, follow-up CAG and IVUS showed residual stenosis with organized thrombus in the culprit lesion, in which a drug-coated stent was directly implanted. He was discharged with a favourable clinical course on Day 23.
Discussion:
We judged that PCI should take precedence over the surgical repair of perforated duodenal ulcer in our case since STEMI was an immediate life-threatening compared to the perforated viscus which had no active exsanguination. Excimer laser coronary angioplasty with manual thrombectomy might be an adequate option to avoid stent deployment and subsequent DAPT in such complex scenarios.
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