STEMI primary PCI: technical tips, including for STEMI with shock- Elias Hanna 

What to do if after wiring and angioplasty, there is still no flow? This is a potential stepwise approach: 1-Ensure your wire is in the true lumen, not subintimal. Make sure the tip is moving freely (+/- the wire can move between the main vessel and the side branch anatomy). 2-If the wire feels appropriate, the most common reason for lack of flow despite PTCA is that the occlusion extends more distally than you thought. Thus, balloon more distally, and you may use a small balloon 1.5 or 2 mm to balloon distally without risking injuring a vessel segment that you may not stent. You may also just “dotter” the vessel by advancing the balloon catheter distally, without even inflating it. 3-if you still have no flow, it is possible that there is a heavy thrombus burden with distal microembolization = “no reflow”. This may be evident by the angiographic appearance of clot. Consider using IIb/IIIa, esp administered locally via dual lumen catheter. 4-Another very helpful tip at any of the above stages: consider distal contrast injection via a dual lumen catheter advanced distally (1 ml or less, via a small 2 cc syringe): - This tells you how big and how open the distal runoff is, and allows you to see that distal vessel if you have not yet. - It may show distal emboli. - It may show no-reflow, in which case the contrast stagnates but delineates the vessel. - It may also show you that your wire is in the subintima (although you should avoid doing it if you already suspect being subtintimal). ++ Do not stent if you have no flow or very poor flow. The only time one may stent with reduced distal flow is when the flow is impaired because of an obvious large dissection. I have not found IVUS to be useful in such a case. When there is no flow, you will have heavy blood stasis artifact and the whole image will be muddy.

Elias, you r really doing good work, by helping Cardiology residents throughout the world, and thereby saving thousands of lives.

Thank you very much! You are my ultimate teacher dr. Hanna! Greetings from Croatia!

Additional note: IVUS or OCT is particularly useful in the following instances in STEMI: **After primary PCI stenting, if hazy areas are seen surrounding the stent: is it thrombus? (treat with IIb/IIIa potentially) or dissection? (treat with additional stenting) **Before primary PCI stenting: -If MI culprit is stent thrombosis--> we need to determine the underlying mechanism: Is it stent underexpansion (treat it with high-pressure balloon or laser)? Is it a mixture of thrombus and heavy in-stent tissue growth (may require DCB or re-stenting for instent tissue growth)? -If SCAD type 2 is suspected but the angiographic features are not definite -If Culprit artery is patent (spontaneous recanalization) with residual angiographic stenosis

thank you dr hanna so informative and helpful. detailed technical advices that guides us in our first steps in the cath lab

Very informative. Thank you

Thank you, Matheus Silva

Very fruitful

Very good thanks very much

Thank you sir

Here are general and additional tips on how to handle heavy thrombus burden that persists or embolizes (macro-emboli) after balloon dilatation: 1-IIb/IIIa inhibitors, consider giving them via a distal dual lumen catheter in patients with slow coronary flow 2-Penumbra thrombectomy catheter (Cat Rx) 3-If large thrombus persists, consider using suction via a deeply advanced Guideliner: you take a properly matched Guideliner (eg, 6 Fr Guideliner in a 6 Fr guide), and you advance it deeply into the thrombus area, then you aspirate via the Tuohy valve. You may even connect the penumbra suction system to the Tuohy while the Guideliner is deep, for stronger suction. 4-For sticky refractory thrombus, may consider intracoronary tpa. TIME trial (JAMA 2019) used slow intracoronary infusion of 10 mg vs 20mg of r-tpa over 5-10 min vs placebo in STEMI after balloon dilatation and before stenting: it showed that r-tpa does not improve eventual flow or outcomes. However, IC r-tpa may be considered for refractory thrombus, using the same 10-20 mg dose, although no data. I would suggest using lower doses, 1-5 mg, administered distally into the thrombus via a dua lumen catheter.

You are god sent

Thanks a lot

The best !

I have a question Dr. Hanna : if you have a patient come in with cardiogenic shock and STEMI but the chest pain began more than 48 hours ago and found a CTO in the prox LAD would you revascularize?

great sir plz sir we are in your experience in cath lab nightmares

Many thanks for such a great lecture Dr Hanna. Just One more thing how should we proceed, if even after wiring and SC ballon inflation we do not see flow in the culprit vessel? Thank you once again.

I'm so glad you did a separate section for RV shock. However, I wonder what is your view on using noradrenaline in cases of right heart predominant cardiogenic shock in AMI? As per your 5 steps in the lecture, usually I have to use a combination of inotropic agents (dobutamine/milrinone) and noradrenaline to keep the MAP ≥ 65 mmHg.

What advice would you give for stemi involving aneurysm....:

Please dr How to size stent ?? After open total occlusion vessel is spastic and small size how to chosse good size especially LAD ?? 2) in bifurcation lesion thrombus in MV and SB how to mange ?? For SB thrombus how to mange ? Maybe ballon dilatation ( small ballon) or kissing ballon MV+SB for flow SB After stent MV 3) thrombus in MV (bifurcation side) sb sub total lesion without thrombus ? How protect SB with hight risk of occlusion ?? Predilate SB befor MV stenting if disseced what about 02 stent technique ?? What u r opion in this situation not predilate For protection use ballon jalied technique ??

Thanks dr Hanna for the excellent update Can you please highlight if there is a place for FFR / IFR in STEMI situation for culprit and non culprit vessels

Ikari guides are not very supportive. When I see someone using an Ikari guide they typically have poor catheter manipulation skills.