1.Christian Assad-Kottner, MD Treatment of a Type 2 MI?

2. A 73 yo M, s/p CABG, underwent left upper lobe lobectomy for lung cancer History Intraoperatively the mid aspect of the LIMA was nicked requiring suture repair. After suture repair surgeon appreciated flow down the LIMA graft. 3. Postoperatively the patient was asymptomatic but the troponin post op day 1 was 2.17 ng/mL (normal range 0.01-0.03 ng/mL). Post-op Day1, echo showed normal wall motion including the anterior wall. History 4. The impression was that this was demand MI (Type II MI) post operatively. the surgeon requested angiography to evaluate the LIMA. Yes I agree it could be a type 2 MI but 5. Outside hospital 2011 angiogram Native vessels Mid LAD 100% OM1 100% Proximal RCA 90% Grafts: SVG to OM1 Patent SVG to Diagonal 1 Patent SVG to PDA 100% LIMA to LAD Patent 6. Last case on a Friday afternoon 7. Angiography showed occluded LIMA at site of presumed vessel injur and subsequent intra-op suture repair. 8. As LIMA was patent Intra-operatively, it was elected to proceed with PCI. 1) A guide wire was passed into the distal LAD. 2) Manual thrombectomy (with only minimal thrombus removal) resulted in flow restoration. 9. After thrombectomy we appreciated a high grade stenosis which was felt to be at the lima lad anastomosis 10. DYE injection revealed free perforation A 2.5x12mm rx balloon was advanced and inflated at the presumed LIMA to LAD anastomotic site 8atm Balloon was reinflated proximal to the perforation 11. We considered the active bleeding stopped secondary to the balloon inflation. Now we are considering options to treat the perforation. 12. Surgeon #1 Surgeon #2 13. After Perforation.. Plan was to consider use of a covered stent via dual catheter technique Left femoral artery was rapidly accessed 8 Fr IM guide catheter was placed in the LIMA ostium after slowly retracting the 6 Fr IM catheter with balloon still inflated. 6Fr IM was then placed carefully at the im ostium Through the 8 Fr guide, A 300cm guidewire was passed into the distal LAD with transient balloon deflation to allow wire passage 14. 1) 3.0 x 26 covered stent advanced proximal to balloon 2) 2.5 x 12 balloon is deflated and pulled proximally 3) 3.0 x 26 covered stent is advanced to perforation site 4) 2.5 x 12 balloon reinflated 5) 180cm runthrough wire (6fr) pulled 6) 3.0 x 26 covered stent is inflated to 10atm x 4 min 15. Angiogram post covered stent implantation My reaction Pre-procedure Hgb 11 Post-procedure Hgb 10.5 16. This is the first case to demonstrate the value of the alternating guide catheter technique ping-pong to treat perforation of LIMA graft. This case also demonstrates the feasibility of placing 2 catheters in a large ostium to improve catheter stability during this emergency procedure. This case also illustrates the importance of having the proper equipment to treat this rare but life threatening complication. Learning Points 17. THANK YOU! What happens in Vegas, stays in