Failure to Retrieve Deformed Stent, and More Problems Arise!

Dr. Alex CHIU

Caritas Medical Centre, Hong Kong

 

A 61-year-old male was admitted in Jan 2017 for acute inferior STEMI treated with successful thrombolytics (TNK). Coronary angiogram in the same admission showed triple vessel disease (mLAD long segment calcified 90%, o/p OM 80%, dLCX 80% (small size), pRCA 90%, o/p PDA subtotal occlusion. (Movie 1) Ad-hoc PCI was done to pRCA, o/p PDA and o/p OM done (DES x 3).

In Apr 2017, staged PCI to mLAD was performed (RRA). 6F EBU 3.5 GC was used. The lesion was pre-dilated with 2.5 NC balloon. (Movie 2) A long 2.5/38 DES was unable to cross the lesion. The proximal stent edge was deformed and shortened by the guiding tip while attempting to withdraw it (no dislodgement). (Movie 3, Movie 4) It could not be withdrawn into GC despite multiple attempts. Then the whole GC and stent catheter were pulled back to ascending aorta. At this stage, it was decided to complete the stenting of mLAD first because it might take long time to retrieve the deformed stent, and there was risk of closure of the ballooned LAD lesion. (Movie 5)

The stenting was done via RFA approach with 6F EBU 3.5 GC. Two shorter DES (2.75/22 + 2.5/18) were easily and successfully deployed to mLAD. (Movie 6) Then the whole RRA GC/stent catheter/GW system was slowly pulled back to brachial artery. With further attempt to withdraw the stent, the stent was further shortened and partially dislodged from stent balloon. (Movie 7, Movie 8, Movie 9, Movie 10) Then micro-snare was used and able to snare the deformed stent, but still could not withdraw it inside GC. (Movie 11, Movie 12) At this stage, it was decided to deploy the deformed stent in upper radial artery. (Movie 13)

Then the unexpanded stent part was expanded with 2.5/12 balloon. (Movie 14) However, it was then complicated with distal radial artery perforation with active contrast extravasation. (Movie 15) Immediate balloon occlusion with the 2.5 balloon was performed x 90 sec. The perforation was sealed off but then acute radial stent massive thrombosis developed! (Movie 16)

Then Export catheter aspiration was performed, followed by intra-radial artery ReoPro via export catheter (same as treating coronary stent thrombosis!). (Movie 17, Movie 18) The stent was further post-dilated with 3.0 and 3.5 NC balloon. (Movie 19) Then another 3.5/12 DES was deployed to cover the deformed stent part. (Movie 20) Final angiogram showed normal radial artery flow with only mild residual thrombus. (Movie 21) The sheath was kept overnight. The patient has been followed up afterwards with no sign of right hand ischemia.