A 67-year-old male patient visited our hospital due to anterior chest pain lasting for more than two hours. He was a current smoker for 40 years and was on anti-hypertensives 10 years.

 No history of diabetes or hypercholesterolemia was noted. His electrocardiogram showed ST elevation more than 2 mm in the lead II, III, aVF. Coronary angiography (CAG) revealed thrombotic total occlusion in distal right coronary artery (dRCA) with poor collaterals. Percutaneous coronary intervention (PCI) using 4.0 mm balloon was performed for dRCA lesion at 16 atm multiple times with the aid of intravenous ReoPro¢ç infusion. However, TIMI flow of RCA was not improved. Thus, thrombus aspiration using Export Catheter was performed and large thrombi were aspirated. However, TIMI flow was not improved. After thrombi aspiration, PCI using 4.0 mm balloon was performed for dRCA and middle RCA (mRCA) multiple times. Final CAG showed no-reflow phenomenon (Fig. 1).
The patient was transferred to CCU and monitored with heparin therapy for 7 days.

 Follow-up CAG performed at one week after the procedure and revealed thrombotic total occlusion in dRCA with large, multiple thrombi. Repeated PCI using 4.0 mm balloon was performed for dRCA and mRCA up to 16 atm multiple times with another infusion of ReoPro¢ç. But, dRCA flow was not improved. Intravascular ultrasound showed multiple, huge thrombi over the entire RCA. We deployed 4.0*28 mm Arthos Inert stent in dRCA. However, TIMI flow was not improved even after stenting and ReoPro¢ç infusion. We performed thrombi aspiration using Export Catheter and big thrombi were aspirated, again. However, final CAG showed no-reflow (Fig. 2).

 The patient discharged and follow-up CAG was performed two months after the procedure. Follow-up CAG showed no change of thrombotic total occlusion in dRCA (Fig. 3). We did not perform any more PCI in this RCA lesion. The patient had uneventful clinical course during 6-month out-patient clinic follow-up.