Abstract
A 72-year-old man underwent primary percutaneous coronary intervention for a subtotal occlusion in the mid-portion of the left anterior descending artery involving a large diagonal branch. After successful stenting with a 3.0/24 mm bare metal stent, during which, the diagonal branch was protected with a coronary guidewire, conventional retrieval of the jailed guide wire was impossible. Subsequently, several attempts at a strong retraction of the wire with the support of a balloon catheter enabled retrieval of the trapped wire. Optical coherence tomography performed after post-dilatation, revealed that the stent was elongated to the left main coronary artery, and the structure of the strut had become coarse in the proximal portion. The stent was believed to have become entangled with the balloon catheter when the guidewire was being pulled. This case suggests that retrieving the jailed guidewire with a balloon catheter carries a potential risk of entrapment in the deformed stent.
1
Introduction
The jailed wire technique is frequently used in bifurcation stenting to prevent acute side branch occlusion; however, retrieval of the guide wire after stenting can sometimes be problematic because of entrapment between the stent and vessel wall. The extent of entrapment depends on the coronary calcification, jailed wire length, and balloon pressure during stent deployment. To cope with this complication, several reports have described methods for retrieval of an entrapped wire . The basic concept of these methods is the same: a small caliber device is advanced against the proximal edge of the stent, and this is followed by pulling of the wire. The devices used include monorail balloon catheter, over-the-wire balloon catheter, and micro-catheters. This procedure can provide selective force transmission for the entrapped guidewire and prevent the deep intubation of the guiding catheter. Although this technique was considered effective, longitudinal and axial deformation, which may cause stent thrombosis , were a concern.
In this report, we describe the case of a patient with entangling of the balloon catheter and the damaged stent strut resulting in severe stent elongation during retrieval of the jailed wire placed in the diagonal branch after stenting of the left anterior descending artery (LAD).
2
Case report
A 72-year-old man with chest pain of sudden onset underwent emergency coronary angiography (CAG), which revealed a subtotal occlusion in the proximal part of the LAD involving a large diagonal branch ( Fig. 1 ). Subsequently, a 6-Fr Taiga EBU guiding catheter (Medtronic, Minneapolis, MN) was inserted through the right radial artery, and predilatation with a 2.25/15 mm balloon catheter was performed. A Runthrough HC guidewire (Terumo, Tokyo, Japan) was inserted into the diagonal branch, and stenting was performed with a 3.0/24 mm Kaname stent (Terumo) at 16 atmospheres ( Fig. 2 ). After checking if the blood flow of the diagonal branch was secure, retrieval of the jailed wire was attempted, but was impossible. Subsequently, the balloon catheter that was used for predilatation was introduced into the proximal edge of the stent, and wire retrieval was attempted. Finally, a strong en bloc retraction of the wire and the balloon catheter enabled retrieval of the trapped wire. On the following fluoroscopy, the stent strut was observed from the left main coronary artery (LMCA) to its original distal end in the LAD, and the configuration of the stent struts became coarse in the proximal portion ( Fig. 3 ). Intravascular ultrasound examination revealed that the number of struts had decreased and that the struts were incompletely apposed to the vessel wall in the proximal portion. A 4.5/12 mm noncompliant balloon was expanded in the LMCA at 12 atmospheres. In the subsequently performed optical coherence tomography, incomplete stent apposition was still observed in the LMCA ( Fig. 4 ). The original stent length of 24 mm had been extended to 35 mm, and the proximal portion was severely extended ( Fig. 5 ). The patient was discharged 24 days later without any adverse event. Even though the patient was treated with a bare metal stent, prolonged dual anti-platelet therapy until the follow-up CAG at 6 months was planned because of the incomplete stent apposition in the LMCA.
