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    Recently a middle-aged man presenting with non ST-segment elevation myocardial infarction (NSTEMI) with significant distal left main disease involving ostia of the left anterior descending (LAD) and left circumflex (LCX) arteries consented for percutaneous coronary intervention (PCI). He underwent successful distal left main stenting with TAP stenting for the LCX lesion, but almost immediately developed a large thrombus in the LAD artery, that was managed with an intra-coronary high dose tirofiban injection. The patient had been pre-loaded both with aspirin and 60 mg of prasugrel before coronary angiography. This case suggested the futility of pre-loading with prasugrel but raised other questions such as the role of upstream glycoprotein IIb/IIIa inhibitors (GPI), particularly in patients with distal left main disease.

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