Out of the Frying Pan into the Fire: A Case Study of NSTEMI Complicated by Complex Bifurcation Lesions

Abstract

Background: Acute coronary syndrome (ACS) encompasses a spectrum of conditions, including unstable angina and myocardial infarction, necessitating swift diagnosis and intervention to prevent morbidity and mortality. Timely management is especially critical for patients presenting with complex coronary anatomies, which can complicate standard treatment protocols. In cases involving bifurcating lesions, the choice of intervention whether single or dual stenting requires careful consideration of anatomical factors to optimize outcomes.

Case Presentation: A 42-year-old female patient with a history of hypertension and diabetes presented initially with NSTEMI but left the hospital against medical advice. Two weeks later, she returned with ST elevation in anterior leads. Cardiac markers were elevated, and echocardiography indicated impaired left ventricular function with a 36% ejection fraction.

Results: Coronary angiography revealed total occlusion of the left anterior descending (LAD) artery, an 80% stenosis in the major diagonal branch, and diffuse 80% disease in the mid-segment of the right coronary artery (RCA). An upfront two-stent strategy using the culotte stenting technique was employed. Following predilation, a Promus stent was deployed in the major diagonal, and a XIENCE stent was placed in the LAD with kissing balloon inflation performed to ensure optimal stent apposition. Post-intervention, TIMI flow III was achieved, leading to improved hemodynamics. Follow-up echocardiography showed an increased ejection fraction of 60%, with the patient remaining pain-free.

Conclusion: This case highlights the importance of early and comprehensive management of ACS in patients with complex coronary lesions. An upfront two-stent strategy proved effective in restoring cardiac function and improving patient outcomes.