Case study: check it before you wreck it

Clinical presentation

• A 52-year-old male presented with stable angina Canadian Cardiovascular Society (CCS) III-IV
• Positive stress-test (anterior wall)
• Coronary angiography (CAG): 70% left main stenosis, 80-90% proximal and mid left anterior descendent (LAD) artery stenosis
• Patient underwent left main and LAD stenting with 2 drug-eluting stents (DES) (2.75 x 38 mm and 4.0 x 20 mm, 18-20 ATM with final kissing balloon dilatation and 4.0 mm non-compliant balloon post-dilatation)
• 8 hours after left main stenting patient developed an episode of ventricular fibrillation. He was transferred to the cathlab for emergency CAG.

Consult the editorial webcast video with comments from the author, from the EuroPCR 2018 session, Lost and found IV: management of stent dislodgment

Procedure

Coronary angiography

Coronary angiography revealed first diagonal branch dissection and thrombotic burden. After 2.0 x 15 mm diagonal branch balloon dilatation, guiding catheter lost it’s position, therefore left main was catheterised again. 

Angiography revealed first diagonal branch dissection and thrombotic burden (Figure 3.1)

Angiography revealed first diagonal branch dissection and thrombotic burden (Figure 3.1)

Lost guiding catheter (Figure 3.2)

Lost guiding catheter (Figure 3.2)

Diagonal branch PCI

Diagonal branch was successfully rewired. During stent delivery it got stuck between the left main stent struts. Stent traction lead to the longitudinal left main stent deformation and second stent dislocation.

Between left main stent struts (Figure 4)

Between left main stent struts (Figure 4)

Control angiography showed that dislocated stent migrated to the left renal artery. Patient was stable, therefore it was decided to complete the diagonal branch PCI at first.

Dislocated stent migrated to the left renal artery (Figure 5.1)

Dislocated stent migrated to the left renal artery (Figure 5.1)

Dislocated stent migrated to the left renal artery (Figure 5.2)

Dislocated stent migrated to the left renal artery (Figure 5.2)

Diagonal branch PCI

The left main and diagonal branch were rewired and 2.25 x 24 mm DES was successfully implanted in the proximal diagonal branch.

Left main and diagonal branch rewired (Figure 6.1)

Left main and diagonal branch rewired (Figure 6.1)

2.25 x 24 mm DES successfully implanted in the proximal diagonal branch (Figure 6.2)

2.25 x 24 mm DES successfully implanted in the proximal diagonal branch (Figure 6.2)

Left main IVUS after diagonal branch PCI

IVUS showed left main stent deformation. There was a gap between stents in left main and LAD, probably due to stent traction.

IVUS showed left main stent deformation (Figure 7.1)

IVUS showed left main stent deformation (Figure 7.1)

Gap between stents in left main and LAD (Figure 7.2)

Gap between stents in left main and LAD (Figure 7.2)

Final angiographic result

Left main stenting with 4.0 x 24 mm DES was performed. Final angiography revealed no stent deformation, no signs of stent thrombosis, residual stenosis ‹30%, TIMI III.

Left main stenting performed (Figure 8.1)

Left main stenting performed (Figure 8.1)

Final angiographic result (Figure 8.2)

Final angiographic result (Figure 8.2)

Renal artery stent extraction

The stent in the renal artery was extracted with the use of hydrophilic coronary wire loop and balloon catheter through the 6F radial introducer and guiding catheter.

Stent extraction (Figure 9.1)

Stent extraction (Figure 9.1)

Coronary wire loop and balloon catheter extraction technique (Figure 9.2)

Coronary wire loop and balloon catheter extraction technique (Figure 9.2)