Abstract
With the continued advancement in PCI equipment and techniques, complications arising from intracoronary manipulation are encountered. Such complications are associated with major adverse outcome including death; myocardial infarction (MI) and the need for urgent coronary artery bypass surgery (CABG), and they require prompt recognition and mediation by the interventional cardiologist. We report a case of a broken stent shaft system in the setting of acute coronary syndrome and its successful retrieval using a non-compliant balloon to trap the proximal portion of the shaft within the guide (“trapping” a procedure used in coronary Chronic Total Occlusions (CTO) interventions) followed by slow withdrawal of the whole system. This was followed by successful PCI of the culprit lesion using a drug eluting stent without any residual complications.
1
Introduction
As the era of PCI continues to advance care in coronary artery disease (CAD), its growing use with time exposes its own set of rare complications. These include instances involving entrapment of catheter remnants like guidewires, balloon with or without stents, stent fracture and Rotablator entrapment in the coronary arteries . Various interventional devices and techniques have been successfully employed to retrieve these devices non-surgically with a high success rate . Although infrequently required, the interventional cardiologist must be well versed in procedural skills necessary to deal with such complications and must have a considerable level of comfort while performing these techniques. We describe a successful case of broken stent shaft of monorail stent system retrieval utilizing balloon inflation.
2
Case and procedure details
A 47-year-old gentleman with past medical history of hypertension, diabetes and end stage renal disease on hemodialysis presented with Non ST Elevation Myocardial Infarction (NSTEMI). Coronary angiography showed the presence of 70%–80% distal LAD stenosis ( Fig. 1 ). The right coronary and left circumflex coronary arteries had non-obstructive CAD. We planned for primary percutaneous intervention (PCI) with a 3.0 × 24 mm drug eluting stent (DES). However the procedure was complicated by complete fracture of the shaft of the stent in the guide thus leaving the stent in the LAD ( Fig. 2 ). When the stent could not inflate, we attempted to withdraw it. On withdrawal, we noticed that the stent-shaft had broken within the guiding catheter at a level not known, as there were no radio-opaque markers on the shaft. This was associated with worsening chest pain and ST segment elevation as the stent was now impeding flow in the LAD.
We initially employed a technique utilizing a goose-neck snare for retrieval of the broken stent shaft but were unsuccessful. A 2.5 × 8 mm non-compliant balloon was then taken into the distal tip of the guiding catheter and inflated until the pressure waveform recorded through the guiding catheter was completely flat (signifying the balloon had totally occluded the guiding catheter) trapping the shaft of the dislodged stent as well as the guide wire on which the stent was lodged ( Fig. 3 A ). Slow withdrawal of the stent with the whole system was performed gently and as the stent and the guide wire moved outwards from the LAD ( Fig. 3 B). The whole system was then removed successfully out of the coronary system ( Fig. 3 C) and the whole body. After retrieval of this entrapped stent, a successful percutaneous intervention was achieved using a distal 2.25 × 16 mm DES overlapped with a proximal 2.5 × 12 mm DES followed with balloon post-dilation. The angiographic results showed Thrombolysis in Myocardial Infarction-3 flow without any residual complications ( Fig. 4 ).
2
Case and procedure details
A 47-year-old gentleman with past medical history of hypertension, diabetes and end stage renal disease on hemodialysis presented with Non ST Elevation Myocardial Infarction (NSTEMI). Coronary angiography showed the presence of 70%–80% distal LAD stenosis ( Fig. 1 ). The right coronary and left circumflex coronary arteries had non-obstructive CAD. We planned for primary percutaneous intervention (PCI) with a 3.0 × 24 mm drug eluting stent (DES). However the procedure was complicated by complete fracture of the shaft of the stent in the guide thus leaving the stent in the LAD ( Fig. 2 ). When the stent could not inflate, we attempted to withdraw it. On withdrawal, we noticed that the stent-shaft had broken within the guiding catheter at a level not known, as there were no radio-opaque markers on the shaft. This was associated with worsening chest pain and ST segment elevation as the stent was now impeding flow in the LAD.
