Unintentional Extraction of Previously Deployed Stent in Ostial Left Anterior Descending Artery during a Dislodged Left Main Stent Retrieval-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY &
CARDIOVASCULAR THERAPY
Stent dislodgment is uncommon complication of
percutaneous coronary procedures (PCI), mainly due to the improvements
in stent design with better diverability, flexibility, and near
universal fabrication of premounted stents, as well as increased overall
physician/operator knowledge and awareness in performing complex and
challenging PCI [1]. Nevertheless, when it occurs it presents a
challenge to even most experienced operators, because it is often
associated with significant morbidity, including systemic or coronary
embolization, acute myocardial infarction (AMI), emergency coronary
artery bypass graft surgery (CABG), or even death [2,3]. Here, we
present a case of stent dislodgment in left main (LM) with subsequent
retrieval of loose stent and unintentional extraction of previously
implanted stent causing intimal tearing of distal LM and ostial LAD.
Fifty-nine years old female patient was admitted for
acute ST elevation myocardial infarction to the catheterization
laboratory two and a half hours after the onset of chest pain. Patient
was hemodinamicaly stabile, Killip class 1 at admission. She had no
previous history of heart disease, with smoking as the only coronary
artery disease (CAD) risk factor. Coronary angiography revealed three
vessel CAD with chronically occluded right coronary artery (RCA),
severely calcified and diseased proximal segment of circumflex artery
(Cx) and culprit occlusion of ostial left anterior descending artery
(LAD) with intraluminal thrombus (Figure 1A & 1B).
At that time, primary PCI of the ostial LAD was
performed, with previous thrombus aspiration using Export AP catheter 6F
(Medtronic, Minneapolis, Minnesota, USA), and final implantation of
Resolute Integrity stent 3.5x15mm at 20atm (Medtronic, Minneapolis,
Minnesota, USA) in ostial segment of LAD with simultaneous protection of
ostial Cx with non-compliant balloon inflation of Sprinter NC 3.0 x15mm
(Medtronic, Minneapolis, Minnesota, USA) up to 12atm (Figure 1C). Final
angio showed good result in ostial/proximal LAD with TIMI 3 flow in the
infarct artery, and minor carina shift in ostial Cx (Figure 1D).
After opening of occluded LAD, severe stenosis of the
mid portion of the artery was appreciated, and after recovery
considered for elective PCI together with proximal Cx stenosis. Complete
ST resolution was achieved in anterior leads and patient was pain free
while being transferred to coronary care unit (CCU). The day after
cardiac enzymes were elevated (CK 845U/L, CK MB 92U/L, troponin I
16.79μg/L) and the patient
was feeling well.
Elective PCI was scheduled in 7 days since patient made
a good recovery in CCU without sings of heart failure and
taking into account the severity of the stenoses in proximal
Cx and mid LAD and the risk of adverse events by prolonging
the revascularization. The PCI procedure was approved by the
Heart Team of our institution, and the patient provided written
informed consent for the PCI procedure. We decided to treat the
proximal Cx first. 7F 4.0 Launcher guide catheter (Medtronic,
Minneapolis, Minnesota, USA) was used and after easy
positioning, floppy wire placement in the distal Cx, predilatation
of the lesion with compliant balloon Sprinter RX 2.5x15 at 10atm,
bare metal stent Liberte 4x18mm (Boston Scientific, Natick, MA,
USA) was implanted at 18atm.
Postdilatation was done with non-compliant balloon
NC Sprinter 4x12mm (Medtronic, Minneapolis, Minnesota,
USA) at 22atm accomplishing good final result despite severe
calcifications (Figure 2A). We then decided to treat the long
and calcified mid LAD lesion (Figure 2B). Soft tip guide wire
was placed in distal LAD without difficulties passing through
the stent in ostial LAD, implanted 7 days ago, and balloon
predilatation of mid and proximal portion of LAD was performed
using compliant balloon Sprinter RX 2.0x20mm at 14atm.
Attempts to pass the bare metal stent Liberte 2.75x28mm
(Boston Sceintific, Natick, MA, USA) in order to cover the whole
lesion were unsuccessful and further persistence resulted in
dislodgment of the stent in the left main (LM) during attempts
to pull-back stent in guide catheter in order to proceed with
further predilatation of the calcified lesion, with simultaneous
loss of distal wire position in LAD and more importantly within
stent carrier lumen (Figure 2C). In order to keep the vessel
open, the other soft wire was placed in the distal LAD next to
the dislodged stent with considerable difficulties. At this point,
the patient was relatively stable, with some chest pain but no
significant ECG changes.
We then attempted to retrieve the stent with Lasso catheter
(Balton, Warszawa, Poland) and finally succeed but at the cost
of pulling back the coronary wires into the guiding catheter
due to inability to catch the stent protruding in the aorta with
the coronary wires next to it. However, the firm resistance and
vigorous force applied to pull the stent back resulted in brakeage
of catheter loop. We then decided to use stronger device
Amplatz Goose Neck Snare Kit (ev3, Plymouth, MN, USA) and
after few attempts we were able to catch the proximal portion
of dislodged stent that protruded through LM in aorta. After
strengthful pulling, finally applied tension resulted in retrieval
of stent in guide catheter and safe removal out of the system,
with a loose of distal wire position due to abrupt jump-back
reaction of the whole system. Examination of retrieved device
revealed that another stent, until that moment fully deployed in
ostial LAD, was mounted as well in distorted fashion alongside
the dislodged undeployed stent (Figure 3A & 3B).
Control angio revealed non-obstructive dissection of LM
and proximal LAD due to initima avulsion and soon after patient
started complaining of chest pain but without significant ECG
changes (Figure 2D). Immediately, we proceeded with PCI of
LAD and after predilatation with Sprinter 2.5x20mm balloon at
14atm we finally implanted two BMS in mid and proximal LAD
(Liberte 2.75x20mm and 3.0x20mm; Boston Sceintific, Natick,
MA, USA).
LM dissection was treated with drug eluting stent
implantation Resolute Integrity 4.0 x 18mm (Medtronic,
Minneapolis, Minnesota, USA) at 12-14atm across the ostium of
side branch, Cx, in provisional bifurcation technique. Final result
showed no residual dissection and excellent overall angiographic
result without need for final kissing dilatation (Figure 3C & D).
After second procedure patient had no enzyme elevation and
was discharged home after 2 days in good health.
We have demonstrated that snare devices can be used
with success to safely retrieve dislodged stent and prevent urgent surgical extraction. However, extreme caution must
be expressed when this is happening through or in vicinity of
recently implanted stents. Various devices and techniques, like
low-profile balloon catheters, gooseneck snares, myocardial
biopsy forceps, baskets, tip-deflecting wires, pincher devices and
multipurpose baskets, have been used for capturing and safely
removing loose parts by percutaneous technique [4]. Some of
these approaches demand that the carrier guide wire remained
intact, but when situations like this occur when medical device
is completely loose due to lost of wire distal position, snares are
reportedly most successfully used devices [5,6].
There have been just a few reports in literature of
simultaneous removal of dislodged and previously implanted
stent with snare device [7,8]. In both cases, previously implanted
stent was at aorto-ostial junction with protruding struts into
aorta. These protruding struts were caught by loop of the snare
simultaneously with the dislodged stent. In our case, extracted
stent was implanted in ostial LAD and could not be accessed
directly by snare, meaning that strut-to-strut interlock between
dislodged and previously implanted stent was firm enough to
pull back both stents when strenuous traction was applied.
We have to emphasize few points as opportunities where
we could have acted in different manner that might prevent
the complication. First and most importantly, small compliant
balloons do not offer enough space for traction-free stent
delivery, especially in case as this one, where unfavourable
anatomy is present and lesion is distal to recently implanted and
un-endothelialized stent. Second, although inflation pressure
for the stent during primary PCI was relatively high (20atm),
intravascular ultrasound (IVUS) could have given us more
information in this particular situation about implanted stent
geometry, under-deployment or possible strut intraluminal
protrusion due to the fact that the stent was implanted
simultaneously with balloon inflation that could lead to proximal
deformation.
Third, every attempt should be made not to lose the distal
wire position in order to prevent or quickly resolve unwanted
abrupt vessel closure that can occur after endothelial injury. One
way to achieve that might be to push the wire deeply forward until backward wire loop is made in aorta, that would allow snare
to approach and grasp the dislodged stent without interference,
and also allow backward motion during catheter and whole
system instant bounce due to accumulated tension. And last
but not least, despite the fact that we were aware after wire
brakeage of thinner loose device occurred that the dislodged
stent was apparently firmly stuck within the vessel, we applied
more tension using higher traction and thicker-wire snare.
Extraction of previously implanted stents is a rare
complication of PCI. Good preoperative strategy with optimal
lesion preparation is essential for preventing these events. In
our case we demonstrated that complicated bailout procedures
such as snare extraction of intravascular objects can be done,
but when performed in vicinity or previously implanted stents,
extreme caution must be taken.
For more articles in Open Access Journal of
Cardiology & Cardiovascular Therapy please click on: https://juniperpublishers.com/jocct/index.php
Comments
Post a Comment