CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 330 AFRICA Angiography revealed a culprit lesion at the bifurcation of the obtuse marginal and atrioventricular groove continuation of the left circumflex (LCx) artery. The left anterior descending artery was unobstructed and the right coronary artery (RCA) showed critical proximal disease with three severe sequential distal lesions (Fig. 2). The patient was loaded with an additional 7 500 U heparin and the LCx lesion was treated with a 3.5 × 28-mm Synergy® everolimus-eluting stent. Despite TIMI-3 flow in the LCx, the patient experienced ongoing chest pain and a decision was made to intervene on the RCA with an Orsiro® 2.75 × 40-mm sirolimus-eluting stent. Despite a good final result, the patient had ongoing chest discomfort. Re-injection of the left coronary artery confirmed the stent being widely patent but with mild haziness at the side branch ostium. A tirofiban bolus of 38 ml was administered, followed by a continuous infusion of 14 ml/h for 24 hours. Forty-six hours later, the patient reported recurrence of chest pain and the ECG revealed an infero-posterior re-infarction, with subsequent development of cardiogenic shock requiring a doubtamine infusion. Emergency angiography revealed subacute stent thrombosis (ST) of both the LCx and RCA stents (Fig. 3). An additional 7 500 U intravenous heparin and tirofiban bolus was administered. Attempts to restore flow in the LCx with multiple low-pressure balloon inflations and thrombus aspiration were unsuccessful. Intracoronary metalyse was injected through a microcatheter, with restoration of minimal flow. The RCA was wired and intracoronary metalyse was administered via a microcatheter, with restoration of flow. The stents appeared well expanded. The patient was loaded with ticagrelor and transferred to the Fig. 2. A: AP caudal projection of the LCA injection at diagnostic angiography. B: LAO projection of the RCA injection at diagnostic angiography. C: RAO caudal projection of the LCA after primary PCI. D: LAO projection of the RCA after primary PCI. AP: antero-posterior; LCA: left coronary artery; LAO: left anterior oblique artery; RCA: right coronary artery; RAO: right anterior oblique artery; PCI: percutaneous coronary intervention. A C B D
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