Delayed Anterior Interventricular Vein Opacification Guides True-Lumen Wiring in Stump-Less LAD Occlusion

Stump-less occlusion of the left anterior descending artery (LAD) during anterior ST-segment elevation myocardial infarction (STEMI) can make identification of the correct guidewire entry point technically challenging, particularly when the occlusion is adjacent to a large diagonal branch. We report a case in which delayed opacification of the anterior interventricular vein (AIV) provided a adjunctive fluoroscopic clue to the expected course of an angiographically ambiguous occluded LAD. A 68-year-old woman initially presented with 4 h of exertional chest pain. The admission electrocardiogram showed no definite ischemic abnormality, and cardiac biomarkers were within normal limits. Eight hours after admission, she developed recurrent severe chest pain with diaphoresis, and repeat electrocardiography demonstrated ST-segment elevation in the anterior precordial leads. Emergency coronary angiography revealed severe diffuse proximal right coronary artery stenosis and complete LAD occlusion immediately distal to a large first diagonal branch, with no clear proximal stump. Repeated attempts to cross the lesion based on the presumed LAD takeoff were unsuccessful. During prolonged cine acquisition, delayed opacification of the AIV became visible. Because the AIV usually courses within the anterior interventricular groove in close relationship to the LAD, its trajectory was used as a fluoroscopic landmark to redirect the guidewire. A conventional workhorse wire was then successfully advanced into the distal LAD true lumen, followed by balloon predilation and implantation of two stents, resulting in restoration of thrombolysis in myocardial infarction (TIMI) 3 flow. This case highlights delayed AIV opacification as a simple, anatomy-based adjunctive clue that may facilitate true-lumen wiring in selected cases of stump-less LAD occlusion during anterior STEMI.