Abstract
Complications of retained or entrapped equipment in the coronary system are still encountered during angioplasty procedures. Although these complications are rare, it is extremely difficult to retrieve such equipments. We report on two cases that a retained IVUS catheter or an entrapped filter wire were retrieved from the coronary system using more simplified technique that does not involve in the usage of snare or any other retrieval tool. After placing an additional guidewire and balloon alongside an equipment, it was easily retrieved from the coronary system just after the proximal balloon deflation.
1
Summary
The presence of intracoronary equipment is a rare complication in clinical practice. A retained IVUS catheter or an entrapped filter wire could be retrieved without difficulty by using proximal balloon deflation technique.
2
Case presentation
2.1
Case 1
A 75-year-old female with previous stent placement (XienceV: 3.5/15 mm: Abott, Santa Clara, USA) in left main trunk coronary artery (LMCA) to left anterior descending artery (LAD) presented with acute coronary syndrome. Coronary angiogram revealed severe stenosis in the ostial left circumflex artery (LCX) ( Fig. 1 A ). The LCA was engaged with 6 F VL 3.5 (Mach I; Boston Scientific, Natick, MA, USA) guide catheter from the right femoral approach. This lesion was crossed with 0.014-inch guidewire (Neo’s Rinate; Asahi Intec, Nagoya, Japan). After predilatation with a 2.0/15 mm balloon (8 atm) (Sprinter legend; Medtronic Inc., Minneapolis, Minnesota), an IVUS examination (Eagle eye: Volcano, Rancho Cordova, USA) was performed. Although the entry of an IVUS catheter into the previous deployed stent strut was possible, it was unable to be retrieved at the stent strut. The change of guide position, gentle manipulation of an IVUS catheter was not effective. Another guidewire placement through the same stent strut as a rail was also unable to retrieve an IVUS catheter. Then the LCA was engaged with another 7 F VL3.0 guide catheter (Mach1) from the left femoral approach ( Fig. 1 C). After 0.014-inch guidewire (Neo’s Route; Asahi Intec, Nagoya, Japan) was crossed through the stent strut from 7 F guide catheter, 2.0/15 mm balloon could also be crossed through the stent strut. After dilatation of this balloon up to 12 atm at the stent strut, an IVUS catheter could not be retrieved from the coronary system ( Fig. 1 B). Finally proximal balloon deflation technique was employed. This balloon was placed in the same position and an IVUS catheter was placed distal to the balloon ( Fig. 1 C). At first, this balloon was inflated up to 8 atm. Just after the deflation of this balloon, an IVUS catheter could be easily pulled and retrieved from the coronary system without resistance ( Fig. 1 D). The concomitant procedure was undertaken with 7 F guide system. After predilataion with 3.5/15 mm balloon for LMCA/LCX (Tazuna, Terumo corp., Tokyo, Japan), a 5 F inner catheter (Dio TM , Goodman corp., Nagoya, Japan) through a 7 F guide catheter was deeply engaged through the stent strut to prevent stent loss or dislodgement ( Fig. 1 E). Then 3.0/8 mm XienceV (Abbot) was crossed within a 5 F inner catheter and deployed as minicrush technique. Final kissing balloon inflation was employed with 3.5/12 mm balloon (VoyagerNC, Abott) for LMCA/LAD and 3.5/8 mm balloon (Quantum maverick, Boston scientific) for LMCA/LCX. Final angiogram revealed that the procedure was successful ( Fig. 1 F).
2.2
Case 2
A 57-year-old male with a history of previous stent placement (Cypher: 3.0/30 mm: Cordis, Johnson & Johnson, Miami FL) in the distal right coronary artery (RCA) presented acute coronary syndrome. Coronary angiogram revealed severe stenosis in the proximal RCA ( Fig. 2 A ). The RCA was engaged with a 6 F SAL 1.0 guide catheter (BriteTip: Cordis) from the right radial approach. This lesion was crossed with 0.014-inch guidewire (RunthroughNS, Terumo). Since an IVUS examination showed hypoechoic plaque with deep ultrasound attenuation at this culprit lesion, a filter wire (Parachute; Tri-Med, Osaka, Japan) was placed at the distal RCA instead of RunthroughNS guidewire while performing angioplasty. Two stents (XienceV: 3.5/18 mm, 3.5/15 mm) were deployed in the proximal RCA at 16 atm. Coronary angiogram showed good dilatation of two stents and embolic material contained within the filter wire ( Fig. 2 B, C). After using thrombus aspiration catheter (Eliminate, Terumo), the microcatheter (Michibiki; Hanako Medical, Saitama, Japan) was used as a recovery catheter. The microcatheter was advanced to collapse and sheath the filter wire with its enclosed debris. This filter wire was inadvertently withdrawn without completely advancing the microcatheter to ensheath the filter wire and entrapped at the deployed stent ( Fig. 2 D). Continued tension on the wire resulted in its being snapped off at the base of the filter. Gentle advancement of filter wire with the microcatheter met resistance on the deployed stent and were unable to be came off from the coronary system. In an attempt to address the problem, a second wire (Eel slender; Japan Lifeline, Tokyo, Japan) was inserted with its tip placed beyond the filter wire. Rotating a second wire with the filter wire was not effective to retrieve the filter wire. 2.5/15 mm balloon (Tazuna, Terumo corp., Japan) was advanced to the distal lesion through the filter wire and inflated at low pressure (2 atm). Retracting the filter wire could not be accomplished because balloon and filter wire could not be retrieved as one unit. Finally this balloon was placed on the stent just proximal of the filter wire. Then proximal balloon deflation technique was employed. At first, this balloon was inflated at 8 atm ( Fig. 2 E). Just after the deflation of this balloon, an entrapped filter wire was came off from the deployed stent and retrieved from the coronary system ( Fig. 2 F, G, H).
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