Acute marginal branch occlusion presenting with anterior wall ST segment elevation during percutaneous coronary intervention of the mid right coronary artery

A 78-year-old male, ex-smoker, with a history of hypertension and hyperlipidemia presented with a one-month duration of worsening angina on exertion. Standard 12 L ECG showed sinus rhythm with early repolarization pattern in the anterolateral leads. Coronary angiography showed minor luminal irregularities in the left coronary vessels (Figure 1 A & B) while the RCA showed high grade non-thrombotic 90% lesion in its mid segment (Figure 2A arrow) followed by another high grade 90% stenosis in the RPDA branch (Figure 2B). A small calibre acute marginal branch (AMB) with an 80% ostial stenosis was noted to take off from the diseased mid RCA segment (Figure 2A arrowhead). Ad hoc percutaneous coronary intervention (PCI) of both the RPDA and mid RCA was carried out.