Abstract
The extraction of a previously endothelialized stent has been rarely reported in the literature. We report a case of a patient with unstable angina due to in-stent restenosis. During percutaneous coronary intervention, a stent was inadvertently dislodged in the ostium of the right coronary artery. Retrieval of the dislodged stent led to unintentional extraction of the previously endothelialized bare metal stent.
1
Introduction
In-stent restenosis of bare metal stents is a common phenomenon and treatment of these lesions with drug eluting stents is routine practice. Stent dislodgment during percutaneous coronary intervention (PCI) is a relatively rare occurrence. Retrieval of dislodged or incompletely deployed stents can be successfully performed using a variety of techniques. However, once stents are deployed and well expanded against the coronary artery, removal appears to be much more difficult. We report a case of a dislodged stent that was successfully retrieved via right radial access using a gooseneck snare. Removal of the stent resulted in inadvertent extraction of a previously endothelialized stent.
2
Case presentation
A 64-year-old male with a history of diabetes, hypertension, hyperlipidemia, chronic tobacco abuse, and peripheral vascular disease presented with complaints of chest pressure with exertion. Given the patient’s numerous risk factors and his typical anginal symptoms, a coronary angiogram was performed. Angiography revealed ostial and mid right coronary artery (RCA) stenosis. Successful PCI was performed with two bare metal stents (3.0 × 16 mm). Patient tolerated the procedure without complications and was started on dual antiplatelet therapy with aspirin and clopidogrel.
Four months later, the patient presented with unstable angina. Given his recent coronary intervention, repeat angiography was pursued. Angiography revealed severe in-stent restenosis of both previously placed stents. Optical Coherence Tomography (OCT) revealed well-expanded stents with concentric in-stent restenosis. Fig. 1 shows the ostial and mid RCA lesion (left) and the corresponding OCT image of the ostial stent revealing significant in-stent restenosis. A 5 F JR 4.0 guide catheter (Cordis Corp., Miami Lakes, Florida) was inserted via the right radial artery. A guidewire (Hi-torque Whisper Wire Extra Support, Abbott Vascular, Santa Clara, CA) was passed through both lesions. Successful PCI of the mid RCA lesion was performed using an everolimus-eluting stent (3.0 × 23 mm). During subsequent stent positioning in the ostial lesion, patient movement resulted in dislodgement of an everolimus-eluting stent (3.5 × 23 mm) within the RCA with protrusion into the aorta ( Fig. 2 ).
The dislodged stent was in ostium of the RCA protruding into the aorta and resulting in decreased flow to the RCA from physically occluding the vessel. The patient began to develop signs and symptoms of vessel occlusion. The patient began to vomit and his electrocardiogram revealed ST elevations in the inferior leads while remaining hemodynamically stable. A 25-mm Amplatz Goose Neck Endovascular Snare (EV3, Plymouth, Minnesota) was positioned at the aorto-ostial junction. The incompletely deployed stent was encircled with the snare and the catheter was advanced to close the snare loop. Gentle traction applied to the stent allowed retraction of both the snare and the stent into the guide catheter and all devices were simultaneously removed. Successful retrieval of the dislodged stent, however, caused inadvertent removal of the previously deployed ostial stent as well as intracoronary tissue ( Fig. 3 ).
Subsequent angiography revealed a spiral dissection (NHLBI Type F) extending to the mid RCA with acute vessel closure ( Fig. 4 ). Antegrade subintimal tracking was used to reenter the true lumen. Balloon dilatation of the entire length of the dissection resulted in restoration of TIMI 3 flow. Paclitaxel-eluting stents were placed from mid to ostial RCA to cover the dissection. Fig. 5 shows the final PCI result.
Histopathologic examination of the extracted stent and the adherent tissue was performed. Microscopic images showed that the fragmented tissue adherent to the stent consisted of fibrous collagenous tissue and smooth muscle cells admixed with chronic inflammatory cells ( Fig. 6 ). Histology also showed scattered groups of chronic inflammatory cells with hemosiderin-laden macrophages. This constellation of findings was consistent with fibrous atheromatous plaque.
Despite these complications, the patient only suffered from a small peri-procedural myocardial infarction (peak troponin 12.4 ng/ml).He was discharged home 48 h after the PCI with complete resolution of his symptoms.
2
Case presentation
A 64-year-old male with a history of diabetes, hypertension, hyperlipidemia, chronic tobacco abuse, and peripheral vascular disease presented with complaints of chest pressure with exertion. Given the patient’s numerous risk factors and his typical anginal symptoms, a coronary angiogram was performed. Angiography revealed ostial and mid right coronary artery (RCA) stenosis. Successful PCI was performed with two bare metal stents (3.0 × 16 mm). Patient tolerated the procedure without complications and was started on dual antiplatelet therapy with aspirin and clopidogrel.
Four months later, the patient presented with unstable angina. Given his recent coronary intervention, repeat angiography was pursued. Angiography revealed severe in-stent restenosis of both previously placed stents. Optical Coherence Tomography (OCT) revealed well-expanded stents with concentric in-stent restenosis. Fig. 1 shows the ostial and mid RCA lesion (left) and the corresponding OCT image of the ostial stent revealing significant in-stent restenosis. A 5 F JR 4.0 guide catheter (Cordis Corp., Miami Lakes, Florida) was inserted via the right radial artery. A guidewire (Hi-torque Whisper Wire Extra Support, Abbott Vascular, Santa Clara, CA) was passed through both lesions. Successful PCI of the mid RCA lesion was performed using an everolimus-eluting stent (3.0 × 23 mm). During subsequent stent positioning in the ostial lesion, patient movement resulted in dislodgement of an everolimus-eluting stent (3.5 × 23 mm) within the RCA with protrusion into the aorta ( Fig. 2 ).
