STEMI with flush occlusion of a coronary artery: An interventional dilemma

Flush occlusions of coronary arteries present with multiple challenges during primary percutaneous coronary intervention (PPCI). We describe a case of anterior ST-elevation myocardial infarction in cardiogenic shock, where it was not possible to identify the origin of left anterior descending artery (LAD) as it was flush occluded and initial attempts to place a coronary guidewire in the LAD during PPCI were unsuccessful. After failed attempts with multiple guidewires, a combined pharmacological-mechanical approach resulted in successful timely revascularization and subsequent recovery of the patient. <Learning objective: Acute flush occlusion of a major coronary artery is a challenge to interventionists as there may not be any clue of occluded coronary artery. In this difficult scenario, when the wire placement is not possible, the intracoronary infusion of a thrombolytic agent helps in visualization of stump of an occluded artery, facilitating its quick wiring and procedure.>