Buy One Get Three Complications

57 year old male with past medical history of diabetes mellitus was admitted for delayed presentation of anterior ST elevation myocardial infarction. He presented for post myocardial infarction angina 3 days after onset. Electrocardiogram showed SR ST segment elevation over v1 – v4. Urgent coronary angiogram was arranged through right radial approach, showing normal left main artery, left circumflex artery, and right coronary artery. A big filling defect compatible with thrombus was located at proximal left anterior descending artery (LAD) (Movie 1, Movie 2, Movie 3). LAD was wired with 0.014” run-through floppy. In view of the heavy thrombus load, an attempt of placement of distal filter device was done. However, the only filter available was SpiderFX 4.0 mm which was too big for the LAD, and migrated proximally to the ostial LAD lesion during deployment. A medium size self-expanding drug eluting stent (DES) was deployed at pLAD at nominal pressure (12 ATM) to reduce risk of no reflow (Movie 4).

Unfortunately, the stent balloon failed to deflate and patient immediately complained of chest pain with blood pressure drop. Because of the unstable hemodynamic, the guiding catheter and stent balloon was removed enblock to allow blood flow down LAD (Movie 5).

Percutaneous coronary intervention was done through right femoral approach. Angiogram with 6Fr EBU 3.75 to LAD showed evidence with no reflow (Movie 6). LAD was wired with run-through floppy guidewire and LAD regained TIMI III flow after injection of 100ug of isoptin. DES 3.5/26 was deployed with pLAD after IVUS run showing intact LM/LAD integrity (Movie 7). Post stenting IVUS run showed satisfactory stent apposition (Movie 8).

The undeflatable stent balloon was pulled to right forearm and was finally punctured by a cut ST01 child catheter to facilitate its removal through 6 Fr radial sheath (Movie 9).

The original self-expanding DES was found to be dislodged stent in the right brachiocephalic artery (Movie 10). Vascular surgeon was consulted but open heart operation to remove the stent was deemed high risk in view or recent myocardial infarction. To secure the stent at a more stable position and avoid its embolization up the carotid artery, a Terumo 0.35 wire was first passed through the expanded stent with the support of JR4 from femoral access. JR4 was then passed through the stent to ensure none of the wire was under stent strut (Movie 11). 300 mm 0.014” guidewire buddied with another 190 cm 0.014” guidewire were passed up through the JR4 guiding catheter and the 300 cm wire was externalized with a 15mm Amplatz Goose neck snare from right radial access (Movie 12). A NC 6.0 balloon was then passed via the externalized PTCA wire to the dislodged stent. It was inflated up to 14 ATM at distal edge of the stent (Movie 13). The inflated balloon and the dislodged stent were then pulled enbloc proximally into the right subclavian artery until a more stable position was met. The self-expanding DES was post dilated with the 6.0 NC balloon at a stable position (Movie 14, Movie 15).

The patient was stable afterwards without peripheral artery injury or clinical stroke.