A 48-year-old male presented at our hospital with typical chest pain. His past medical history was unremarkable. His coronary risk factors only included "current smoker". On physical examination, he had a systolic blood pressure of 120 mmHg and a heart rate of 62 beats per minute. An initial electrocardiogram (ECG) showed no definite ST segment change and sinus rhythm (). Initial creatine kinase-MB and cardiac troponin I levels were in the normal range. Transthoracic echocardiography showed no regional wall motion abnormality and normal left ventricular function. We administered aspirin 300 mg for 1 day. CAG revealed a filling defect of the distal left anterior descending artery (dLAD), distal left circumflex artery (dLCX) and LMA (). We decided to aspirate the LMA thrombus and to do PCI at the dLAD and dLCX. A guiding catheter was positioned in the left coronary artery ostium. At that time, he complained of aggravating chest pain. On CAG, the distal region of the 1st diagonal branch (D1) and the obtuse marginal branch (OM) were not visualized (). We thought that this event had developed due to coronary embolization that resulted from the migration of thrombi into the LMA during CAG. Intravascular ultrasonography showed the LMA thrombus (). We tried to aspirate the thrombus in the LMA using a guiding catheter and to do balloon angioplasty in the dLAD and dLCX. Balloon angioplasty was successful only for D1 (). However, the dLAD, dLCX and OM had Thrombolysis In Myocardial Infarction (TIMI) grade 1 flow in spite of repeated balloon angioplasty. Applied platelet glycoprotein IIb/IIIa receptor antagonist (Abcimixab, Reopro®) and balloon angioplasty of the dLAD, OM and dLCX were done sequentially. However, filling defects in the dLAD, OM and dLCX remained ().\nWe cared for the patient in the cardiovascular care unit. Creatine kinase-MB and cardiac troponin I levels were elevated to 349.4 ng/mL and 40.91 ng/mL, respectively. Follow up ECG showed a 3 mm ST segment elevation at leads II, III, aVF and V3-5 after angiography (). We thought that the AMI developed due to distal embolization of the LMA thrombus during angiography. Laboratory profiles associated with hypercoaguability such as lupus anticoagulant, protein C activity 102% (NL 70-130%), protein S activity 74% (NL 73.7-146.3%), D-dimer 0.36 µg/mL (NL 0.0-0.4 µg/mL), antithrombin III 91% (NL 80-120%) and homocysteine 12.2 µmol/L (NL 5.0-15.0 µmol/L) were in the normal range.\nAfter 3 days of intravenous unfractionated heparin (25,000 IU/day), follow-up CAG showed only slight resolution of the filling defect and only in the dLAD, not in the OM and dLCX (). He had no chest pain and was discharged on triple antiplatelet agent. After 1 year of this treatment, he experienced no chest pain and, on follow up CAG, had no significant stenosis or intracoronary filling defects ().
A 75-year-old male patient known to have diabetes mellitus, hypertension, dyslipidemia, and coronary artery disease underwent coronary artery bypass graft surgery in 2004 left internal mammary artery to left anterior descending artery, saphenous vein graft to right coronary artery and a jump (Y) graft to obtuse marginal 1 and obtuse marginal 2 presented to the emergency department complaining of chest pain and shortness of breath for three days. He was admitted to the coronary care unit as acute coronary syndrome, non-ST elevation MI and started on ACS medication. ECG showed lateral ST-T wave changes and Troponin I was positive, 1.8 ng/ml. The echocardiogram showed moderate hypokinesis of posterlateral wall and the ejection fraction was 50%.\nOn the second day patient underwent a coronary angiogram, which showed a patent saphenous graft to the right coronary artery; patent left internal mammary artery to left anterior descending artery; and patent Y-graft to obtuse marginal 2 and thrombus in the saphenous graft to obtuse marginal 1 [].\nPercutaneous intervention was performed using a manual suction technique with a small pediatric microvena snare catheter 4F (ev3, Plymouth, Minnesota. USA). After manual suction few times the graft become clear [] and both small organized and fresh clots were removed [] and no angioplasty was done in this case. Patient was discharged from the hospital in a very stable condition in a few days.