Abstract
We describe our solution to the unusual situation of an inflated, large coronary stent (3.5 mm diameter) which became dislodged from the ostium of the right coronary artery after deployment during a transradial procedure. We discussed tips for retrieval from the radial artery while preserving the access for completion of the procedure.
1
Introduction
Stent dislodgment or migration is a relatively rare but serious complication of PCI, arising especially when stents are forcibly pushed in calcified and tortuous lesions . Several methods and tips for stent retrieval have been described, which are applicable to both femoral and radial approach . Only few of these cases, however, have specifically dealt with transradial stent retrieval , with no report concerning inflated stents.
We describe the special situation of an inflated, large coronary stent (3.5 mm diameter) dislodged from the right coronary artery (RCA) ostium after deployment, which was retrieved from the radial artery while preserving the access for completion of the procedure.
2
Case report
A 66-year-old hypertensive, dyslipidaemic male was admitted to our department due to recurring angina and positive exercise stress test. He had known coronary artery disease: 3 years before he had undergone percutaneous coronary intervention (PCI) with drug-eluting stent implantation to the left anterior descending artery (LAD) and bare metal stent (BMS) to the right coronary artery (RCA). Coronary angiography was performed through right transradial approach using a 6 F Radifocus II 25-cm long sheath (Terumo Corporation, Japan), and showed a significant de novo RCA ostial stenosis, just proximal to the previously implanted stent ( Fig. 1 A ). Intermediate LAD stenosis and distal collateralized occlusion of the left circumflex artery (LCX) were also present ( Fig. 1 B).
A strategy of ad hoc PCI to the RCA was chosen, and a Judkins Right 4 6 F guiding catheter was used to engage the artery. Two 0.014” coronary guidewires (Balance Middleweight Universal, Abbott Vascular, USA) were positioned in the RCA: one in acute marginal branch for providing stability, the other in the postero-lateral branch. Direct stenting of the lesion was performed using a 3.5 × 16 mm BMS (Chrono Carbostent, CID, Italy). Because of perceived incomplete ostial coverage, a second 3.5 × 8 mm Chrono Carbostent was deployed, just proximal and partially overlapping with the previous one ( Fig. 2 & Supplementary Video 1 ). After deployment and balloon removal from the ostium, however, the second stent was observed in aorta, dislodged from the coronary ostium ( Supplementary Video 2 ). The stent balloon was then carefully advanced over the coaxial guidewire, partially protruding from the distal end of the dislodged stent and inflated at high pressure (>16 atm) ( Fig. 2 B). We did not attempt to pull the entire stent-balloon system into the guiding catheter and retracted the three elements as a single unit. Deep inspiration was requested to the patient in order to straighten the tortuous anonymous trunk during slow pullback, where some resistance was felt ( Fig. 3 A & Supplementary Video 3 ). No other significant resistance was observed ( Fig. 3 B&C) until the unit was in the brachio-radial transition ( Fig. 3 D), where no further pulling force was applied. At this point, the 6 F sheath was exchanged over the two 0.014” guidewires for a 7 F 12-cm sheath (Terumo). An Amplatz GooseNeck Microsnare 4 mm system (ev3, USA) was introduced from the 7 F sheath, with the loop encircling the two wires. The stent was successfully snared at the brachio-radial junction ( Fig. 4 A) and retracted within the sheath, applying moderate pull. The deployed stent was successfully exteriorized through the sheath hemostatic valve ( Fig. 4 B&C). The PCI procedure was eventually completed by implantation of another 4.0 × 12 mm Chrono Carbostent at the ostium of the RCA. No dissection or perforation of the radial artery was evident at the final angiography.
2
Case report
A 66-year-old hypertensive, dyslipidaemic male was admitted to our department due to recurring angina and positive exercise stress test. He had known coronary artery disease: 3 years before he had undergone percutaneous coronary intervention (PCI) with drug-eluting stent implantation to the left anterior descending artery (LAD) and bare metal stent (BMS) to the right coronary artery (RCA). Coronary angiography was performed through right transradial approach using a 6 F Radifocus II 25-cm long sheath (Terumo Corporation, Japan), and showed a significant de novo RCA ostial stenosis, just proximal to the previously implanted stent ( Fig. 1 A ). Intermediate LAD stenosis and distal collateralized occlusion of the left circumflex artery (LCX) were also present ( Fig. 1 B).
