L e t t e r t o t h e E d i t o r 225Dear Sir, Acute multi-coronary thrombotic occlusion is an uncommon presentation of ST-segment elevation myocardial infarction (STEMI). Only a few reports of this condition have been published to date and the appropriate management options are unclear.(1) The present report draws attention to simultaneous coronary thrombosis in the right coronary artery (RCA) and left anterior descending artery (LAD) and discusses the possible mechanism and treatment strategy.A 51-year-old man presented with typical chest pain of four hours' duration and pulmonary oedema. His cardiovascular risk factors included Type 2 diabetes mellitus, hypertension, dyslipidaemia and smoking (ten cigarettes per day for the past 20 years). The patient received intranasal oxygen therapy, intravenous morphine and furosemide in the emergency department. A loading dose of aspirin 300 mg and clopidogrel 600 mg was administered. Electrocardiography revealed ST-segment elevation in the inferior leads. Coronary angiograms showed a thrombotic occlusion of the mid-RCA and the proximal LAD, with thrombolysis in myocardial infarction (TIMI) 0 flow (Figs. 1a & b).Primary percutaneous coronary intervention (PCI) was performed via a 7 French (Fr) sheath in the right common femoral artery. The patient received heparin anticoagulation during PCI, guided by an activated clotting time. Initial results with plain balloon angioplasty were unsatisfactory for both the lesions, with a large thrombus burden. Thrombus was aspirated from the RCA and the LAD with a 7 Fr Thrombuster aspiration catheter (Kaneka Medix Corp, Shinagawa-ku, Tokyo, Japan). TIMI 3 flow was achieved in both the arteries, with a residual stenosis of 50%-60% in the mid-RCA and 60%-70% in the mid-LAD (Figs. 2a & b). The coronary arteries were ectatic. An intra-aortic balloon pump was inserted for haemodynamic stability. During PCI, the patient had also received two boluses of eptifibatide (180 µg/kg given ten minutes apart), followed by an infusion for 24 hours (2.0 µg/kg/min). As reperfusion was successful following the aspiration thrombectomy, stenting during primary PCI was deferred. Following PCI, low-molecular-weight heparin (1 mg/kg body weight, twice daily) was administered during the period of index hospitalisation. Investigations did not reveal