Consult this clinical case on a 79-year-old male with long, tortuous and calcified LAD lesion from the Juan Ramon Jimenez Hospital, Huelva - Spain on how to handle the situation with a stent loss to the proximal LAD.
Pre-dilation with semi-compliant balloon 2.5 x 20 mm (Figure 1)
Pre-dilation with semi-compliant balloon (Figure 1)
Pre-dilation with semi-compliant balloon (Figure 1)
Implant of two sirolimus drug-eluting stents 2.5 x 22 mm and 3.5 x 18 mm in the middle and proximal segment of LAD (Figure 2). After that, a dissection of the distal edge was observed (arrow).
Detection of distal edge (Figure 2)
Detection of distal edge (Figure 2)
Solving distal edge dissection
Stent pass was tried to distal edge unsuccessfully (used of catheter extension, buddy guide and several pre-dilatations with non-compliant balloon of 3 mm).
Multiple predilatation with NC balloon
Multiple predilatation with NC balloon
After that, a new attempt to progress stent was performed, but a radiopaque image was observed, suggesting a loose stent on the proximal segment of LAD (arrow).
We tried to catch the stent with two guides, but failing.
Attempt to catch stent with two guides
Attempt to catch stent with two guides
The stent was still there.
Position of stent
Position of stent
We then decided to crush the stent.
Final angiographic result
And it was still there, and finally it had embolised to the distal segment.
Stent embolised to distal segment
Stent embolised to distal segment
Prolonged dilation is performed on the distal dissection, improving the final angiographic result.
Prolonged dilation performed
Prolonged dilation performed
Three years later
Asymptomatic
Atypical chest pain
Positive treadmill exercise stress test clinically
Coronary angiogram was performed
Optical Coherence Tomography (OCT)
OCT (1) where the previous underexpanding crushed stent is endothelised without severe hyperplasia on distal segment of LAD. OCT image (2) where we can see the previous implanted stent on the middle segment of OCT and the crush stent inside at the bottom of the artery.
In case of an underexpanded stent release, we have several options to solve as the used of several guides to catch it, stenting, crushing or embolise it distally.
Intracoronary imaging techniques provide an useful information to evaluate the final result and to decide the final management as in this case.
In case of embolisation of underexpanded stent, OCT evaluate the endothelisation and the hyperplasia in the follow-up.
24 Jan 2019
Case study: Is it really loose?
Coronary stent loss complications
Consult this clinical case on a 79-year-old male with long, tortuous and calcified LAD lesion from the Juan Ramon Jimenez Hospital, Huelva - Spain on how to handle the situation with a stent loss to the proximal LAD.
Authors
Hospital Juan Ramón Jiménez - Huelva - Huelva, Spain
Interventional cardiologist / Cardiologist
Complejo Hospitalario Universitario de Huelva - Huelva, Spain
Interventional cardiologist / Cardiologist
Hospital Juan Ramon Jimenez - Huelva, Spain
Hospital Juan Ramón Jiménez - Huelva - Huelva, Spain
Juan Ramon Jimenez Hospital - Huelva, Spain
Interventional cardiologist / Cardiologist
JUAN RAMON JIMENEZ-HUELVA - HUELVA, Spain
By F.J. Caro Fernandez , J. Roa Garrido , S.J. Camacho Freire , U.F. Martínez Capoccioni , A. Gomez Menchero , J. Diaz Fernandez
Clinical presentation
Long tortuous and calcified lesion in mid-LAD
Long tortuous and calcified lesion in mid-LAD
Consult the editorial webcast video with comments from the author, from the EuroPCR 2018 session, Look again: unexpected coronary complications
Procedure
LAD angioplasty
Pre-dilation with semi-compliant balloon (Figure 1)
Pre-dilation with semi-compliant balloon (Figure 1)
Implant of two sirolimus drug-eluting stents 2.5 x 22 mm and 3.5 x 18 mm in the middle and proximal segment of LAD (Figure 2). After that, a dissection of the distal edge was observed (arrow).
Detection of distal edge (Figure 2)
Detection of distal edge (Figure 2)
Solving distal edge dissection
Stent pass was tried to distal edge unsuccessfully (used of catheter extension, buddy guide and several pre-dilatations with non-compliant balloon of 3 mm).
Multiple predilatation with NC balloon
Multiple predilatation with NC balloon
After that, a new attempt to progress stent was performed, but a radiopaque image was observed, suggesting a loose stent on the proximal segment of LAD (arrow).
Loose stent
Loose stent
Solving stent
We tried to catch the stent with two guides, but failing.
Attempt to catch stent with two guides
Attempt to catch stent with two guides
The stent was still there.
Position of stent
Position of stent
We then decided to crush the stent.
Final angiographic result
And it was still there, and finally it had embolised to the distal segment.
Stent embolised to distal segment
Stent embolised to distal segment
Prolonged dilation is performed on the distal dissection, improving the final angiographic result.
Prolonged dilation performed
Prolonged dilation performed
Three years later
Optical Coherence Tomography (OCT)
OCT (1) where the previous underexpanding crushed stent is endothelised without severe hyperplasia on distal segment of LAD. OCT image (2) where we can see the previous implanted stent on the middle segment of OCT and the crush stent inside at the bottom of the artery.
Key messages
The author's comments on this case study is also available in the editorial webcast from EuroPCR 2018.
Discover Look again: unexpected coronary complications
Don't hesitate to also consult the Clinical Atlas of Intravascular Optical Coherence Tomography (OCT) app
For further reading, please consult Total stent and Guidewire loss
Disclaimer
This case report does not reflect the opinion of PCR or PCRonline, nor does it engage their responsibility.
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