Abstract
Our case reports the first migration of a stent already deployed at high pressure in the main vessel during a 2-stent strategy for a bifurcation lesion using T and protrusion technique. The Kissing balloon was not optimal and could have led to an insufficient strut/cell opening and then to LAD stent pulled back into the artery tree. This case report highlights the importance of an optimal Kissing Balloon in two stent bifurcation technique.
A 53 year-old male presented with a typical stable chest pain. Computed tomography angiography (CTA) documented a significant bifurcation lesion between the left anterior descending coronary artery (LAD) and a diagonal branch. The coronary angiogram confirmed the bifurcation stenosis, type [1,0,1] of the Medina classification ( Fig. 1 A ).
A right transradial approach was used with a 6 Fr EBU guiding catheter. We first planned to use a single stent strategy with a provisional stenting of the side branch. An appropriately sized Resolute Integrity Zotarolimus drug-eluting stent (DES) (Medtronic Vasc, Inc.; Santa Rosa, CA, USA) of 4.0 mm diameter and 15 mm length was implanted at 20 atm in the LAD covering the diagonal branch. Angiographic result on the LAD was satisfactory but there was a plaque shift on the diagonal artery with a stenosis superior to 50% angiographically ( Fig. 1 B). So, a floppy guidewire was advanced across the stents struts into the side branch and a simultaneous final kissing balloon was performed using 2 non-compliant balloons with an appropriately size ratio 1–1 ( Fig. 1 C). Angiographic result was good on the LAD but not on the diagonal artery ( Fig. 1 D). We therefore decided to do a T and Protrusion technique (TAP) with implantation of a second DES on the diagonal ostium through the LAD stent. We chose a Xience Everolimus drug-eluting stent (Abbott Vascular, Santa Clara, California, USA) of 2.5 mm diameter and 8 mm length. Due to the impossibility of positioning the stent far enough in the side branch, we decided to remove the stent and to perform an additional balloon predilatation. During side branch stent removal maneuver, the LAD stent was dislodged and pulled back into the aorta ( Fig. 2 G ) and then all through the artery tree until it was blocked in the radial artery. Both stents – the one of the Diagonal (still on the wire) and the one on the LAD – stayed crushed all along the pullback. A right transfemoral approach with a 7 Fr EBU guiding catheter was used in emergency to control the coronary angiogram showing patent LAD and diagonal vessels with TIMI 3 flow grade in both arteries ( Fig. 1 E). We therefore performed a mini-crushed stent technique on the bifurcation using a 2.5/12 mm Xience Everolimus drug-eluting stent in the diagonal branch crushed by a 4.0/15 mm Resolute Integrity Zotarolimus drug-eluting stent deployed at 20 atm. Fig. 1 F shows final result.
