Abstract
A 69-year-old male patient with a history of percutaneous coronary intervention (PCI) to the proximal left anterior descending coronary artery (LAD) underwent another PCI to the stenosis of the medium LAD as part of therapy for angina pectoris. Interruption of stent delivery because of past stent led to stent entrapment and a stuck guidewire. A snare catheter device was applied to retrieve the stent; however, the device lost mobility. Surgical removal and coronary artery bypass grafting (CABG) were required. We herein report some surgical techniques for resolving this complication of PCI.
< Learning objective: Despite the recent advancements in devices and/or technical skills, the complications of PCI will never be eliminated. This case report provides a suggestive lesson with regard to open heart surgery for PCI complication; furthermore, only a few reports have described details concerning these PCI complications from the viewpoint of a surgeon. Physicians and surgeons should learn the emergent surgical techniques for resolving PCI complications.>
Introduction
Despite advancements in devices and/or technical skills, there will always be complications concerning percutaneous coronary intervention. Most complications are resolved via endovascular techniques. However, some cases require open heart surgery. This is a surgical case report describing surgical techniques for resolving PCI complications, such as an entrapped stent and a stuck snare device.
Case report
The patient was a 69-year-old male with a history of angina pectoris at the age of 58 years old with subsequent PCI to a proximal LAD stenosis. Similar symptoms resulted in the patient undergoing coronary angiography approached via the left radial artery. There was no in-stent restenosis, but he was found to have 90% stenosis in the medium part of the LAD. Intravascular ultrasound showed that one-to-two stent strut was protruded at the ostium of LAD. After expanding the lesion with a balloon device, another stent was to be placed in the LAD. However, the previous stent interrupted ®several devices, such as GuideLiner catheter (Vascular Solutions Inc., Minneapolis, MN, USA), were used. Furthermore, it was found that the stent had dislodged to the ostium of the left coronary artery. The snare device (Goose Neck Snare®, Medtronic, Dublin, Republic of Ireland) was used to retrieve the stent and the guidewire; however, this resulted in immobilization of all the equipment ( Fig. 1 ). Since it was difficult to recover the stent via endovascular approaches, the patient was transferred to our hospital for surgical retrieval of all the equipment.
After establishing cardiopulmonary bypass and achieving cardiac arrest, both the aorta and the catheter were cross-clamped. Transection of the aorta exposed the snare device, which seized the tip of the stent tightly. The stent was fully stretched with the guidewire inside and hanging from inside of the ostium of the left coronary artery. Both the stent and the guidewire were cut near the seizing point of the snare device to release the tension of each device that was stuck. Initially, only the guidewire was held in the cutting edge of the stent, and it was being pulled out with little resistance. Subsequently, the stent was carefully retracted, resulting in easy removal of the entire length of the stent from the LAD ( Fig. 2 ). Coronary artery bypass grafting was performed to the LAD along with a great saphenous vein graft to preclude coronary thrombosis secondary to remnants. The remaining stent and guidewire in the aorta were removed, together with the snare device, from the radial artery sheath after aortic declamping. Extracorporeal circulation time, cross-clamping time, and operation time were 114, 82, and 286 min, respectively.
