Case study: coughing concomitant with stent deployment leading to embolisation of a right coronary artery stent
Coronary stent loss complications
Consult this clinical case by N. B. Fitzpatrick, I. Yearoo and J. Cosgrave from St James’s Hospital, Dublin - Ireland on how to manage a stent floating in the subclavian artery.
A 56-year-old male, with previous coronary stent implantation, referred for diagnostic angiography on the basis of a three month history of exertional chest pain despite 2 anti-anginal agents and a positive exercise stress test (angina at 2 minutes).
Diagnostic angiography revealed a normal left main (LM), a patent stent in the left anterior descending artery (LAD) and at least moderate left circumflex (LCx) disease. The middle segment of the right coronary artery (RCA) was critically stenosed.
Appropriate dual antiplatelet agents were commenced and two weeks later the patient was brought to the coronary catheterisation laboratory for planned angioplasty to the RCA and functional flow reserve (FFR) testing +/- angioplasty to the LCx.
RCA approached with a 6 French Judkins Right 4 (JR4) guide catheter via the right radial artery, RCA and marginal branch wired with Asahi Sion Blue Wire.
RCA stenosis and guide wires in place (Figure 4)
RCA stenosis and guide wires in place (Figure 4)
A 3.5 x 48 mm DES deployed at 14 ATM, lesion having been predilated with 3.0 x 12 NC balloon to 14 ATM. The DES was difficult to deliver requiring deep engagement with the JR4 guide.
Distal to the first stent and proximal to the bifurcation of the posterior descending artery (PDA) a 3.0 x 24 mm DES was delivered with an initial pressure of 10 ATM, then 14 more proximally and 32 ATM at the stent overlap. A 3.5 x 28 DES still on its delivery balloon about to be deployed in the proximal RCA (Figure 5).
As the proximal RCA stent was being deployed, the patient coughed vigorously, leading to guide and stent/balloon prolapse, here we see the inflated delivery balloon, but the stent is not visible because it is within the field (Figure 6).
Difficulty to evaluate stent position (Figure 6)
Difficulty to evaluate stent position (Figure 6)
The errant DES was located in the right subclavian artery. Wired through strut with the Asahi Blue wire, gaining traction with the deliver balloon we were able to bring the DES into a more stable position in the brachial artery (Figure 7).
DES located in the right subclavian artery (Figure 7)
DES located in the right subclavian artery (Figure 7)
Multiple attempts to rewire the stent were only partially successful, we were able to wire through struts of the DES but not through the main lumen, preventing us from passing a balloon completely through the DES. At this point we gained access to the right femoral artery via a 8 Fr sheath and inserted a JR4 guide up to the right subclavian artery with the aid of a Terumo Glidewire.
Efforts to capture the stent with an Amplatz GooseNeck device via the RRA guide were also fruitless, primarily due to the fact that while trying to encapsulate the stent with the snare fibres the stent was being displaced from the brachial artery into the subclavian artery.
Multiple capture attempts lead to progressive deformation and compression of the stent. Eventually a Merit Ensnare device was utilised through the right femoral guide. In the image above we see the guide catheter from the RRA providing a platform allowing the Ensnare from the right femoral guide to surround the stent leading to its capture (Figure 8).
Attempt to snare the stent (Figure 8)
Attempt to snare the stent (Figure 8)
The DES captured within the Merit Ensnare snare being tractioned with some difficulty into the femoral sheath, with care taken to ensure the stent was kept whole (Figure 9).
Stent entrapment (Figure 9)
Stent entrapment (Figure 9)
Final angiographic result
Heavily deformed DES within the GooseNeck snare at the end of a JR4 guide, complete and thankfully outside the patient (Figure 10.1).
Captured DES within the GooseNeck snare (Figure 10.1)
Captured DES within the GooseNeck snare (Figure 10.1)
Final angiographic result of the RCA following eventual successful insertion of DES to proximal RCA (Figure 10.2).
10 Dec 2018
Case study: coughing concomitant with stent deployment leading to embolisation of a right coronary artery stent
Coronary stent loss complications
Consult this clinical case by N. B. Fitzpatrick, I. Yearoo and J. Cosgrave from St James’s Hospital, Dublin - Ireland on how to manage a stent floating in the subclavian artery.
Authors
Interventional cardiologist / Cardiologist
Beaumont Hospital - Dublin, Ireland
Interventional cardiologist / Cardiologist
Bristol Heart Insitute - Bristol Heart institute, United Kingdom
By N. Fitzpatrick , I. Yearoo
Clinical presentation
Consult the editorial webcast video with comments from the author, from the EuroPCR 2018 session, Lost and found III: stent retrieval techniques
Procedure
RCA approached with a 6 French Judkins Right 4 (JR4) guide catheter via the right radial artery, RCA and marginal branch wired with Asahi Sion Blue Wire.
RCA stenosis and guide wires in place (Figure 4)
RCA stenosis and guide wires in place (Figure 4)
A 3.5 x 48 mm DES deployed at 14 ATM, lesion having been predilated with 3.0 x 12 NC balloon to 14 ATM. The DES was difficult to deliver requiring deep engagement with the JR4 guide.
Distal to the first stent and proximal to the bifurcation of the posterior descending artery (PDA) a 3.0 x 24 mm DES was delivered with an initial pressure of 10 ATM, then 14 more proximally and 32 ATM at the stent overlap. A 3.5 x 28 DES still on its delivery balloon about to be deployed in the proximal RCA (Figure 5).
Attempt to implant DES to proximal RCA (Figure 5)
Attempt to implant DES to proximal RCA (Figure 5)
As the proximal RCA stent was being deployed, the patient coughed vigorously, leading to guide and stent/balloon prolapse, here we see the inflated delivery balloon, but the stent is not visible because it is within the field (Figure 6).
Difficulty to evaluate stent position (Figure 6)
Difficulty to evaluate stent position (Figure 6)
The errant DES was located in the right subclavian artery. Wired through strut with the Asahi Blue wire, gaining traction with the deliver balloon we were able to bring the DES into a more stable position in the brachial artery (Figure 7).
DES located in the right subclavian artery (Figure 7)
DES located in the right subclavian artery (Figure 7)
Multiple attempts to rewire the stent were only partially successful, we were able to wire through struts of the DES but not through the main lumen, preventing us from passing a balloon completely through the DES. At this point we gained access to the right femoral artery via a 8 Fr sheath and inserted a JR4 guide up to the right subclavian artery with the aid of a Terumo Glidewire.
Efforts to capture the stent with an Amplatz GooseNeck device via the RRA guide were also fruitless, primarily due to the fact that while trying to encapsulate the stent with the snare fibres the stent was being displaced from the brachial artery into the subclavian artery.
Multiple capture attempts lead to progressive deformation and compression of the stent. Eventually a Merit Ensnare device was utilised through the right femoral guide. In the image above we see the guide catheter from the RRA providing a platform allowing the Ensnare from the right femoral guide to surround the stent leading to its capture (Figure 8).
Attempt to snare the stent (Figure 8)
Attempt to snare the stent (Figure 8)
The DES captured within the Merit Ensnare snare being tractioned with some difficulty into the femoral sheath, with care taken to ensure the stent was kept whole (Figure 9).
Stent entrapment (Figure 9)
Stent entrapment (Figure 9)
Final angiographic result
Heavily deformed DES within the GooseNeck snare at the end of a JR4 guide, complete and thankfully outside the patient (Figure 10.1).
Captured DES within the GooseNeck snare (Figure 10.1)
Captured DES within the GooseNeck snare (Figure 10.1)
Final angiographic result of the RCA following eventual successful insertion of DES to proximal RCA (Figure 10.2).
Final angiography of the RCA (Figure 10.2)
Final angiography of the RCA (Figure 10.2)
Key messages
The author's comments on this case study is also available in the editorial webcast from EuroPCR 2018.
Discover Lost and found III: stent retrieval techniques
For further reading, please consult Stent loss in aorta or peripheral circulation
Disclaimer
This case report does not reflect the opinion of PCR or PCRonline, nor does it engage their responsibility.
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