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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 148-150

Successful retrieval of a partially degloved and distorted coronary stent using novel improvised technique


1 Department of Cardiology, Jawaharlal Nehru Medical College, Sawangi, India
2 Department of Cardiology, Shree Krishna Hrudayalaya and Critical Care Centre, Nagpur, Maharashtra, India

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Anil R Jawahirani
Department of Cardiology, Jawaharlal Nehru Medical College, Sawangi, Maharashtra 440003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_8_18

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  Abstract 

We report a case of retrieval of partially degloved and distorted coronary stent using a novel improvised technique of higher sized sheath. The stent could not be removed into the regular guiding catheter of 6F. We removed the partially degloved coronary stent by withdrawing it into the descending aorta and then exchanging femoral sheath with higher sized (11F) femoral sheath followed by removing the stent into 11F sheath.

Keywords: Degloved stent, percutaneous coronary intervention, retrieval


How to cite this article:
Jawahirani AR, Fulwani M, Sane D, Gadkari P. Successful retrieval of a partially degloved and distorted coronary stent using novel improvised technique. Indian Heart J Interv 2018;1:148-50

How to cite this URL:
Jawahirani AR, Fulwani M, Sane D, Gadkari P. Successful retrieval of a partially degloved and distorted coronary stent using novel improvised technique. Indian Heart J Interv [serial online] 2018 [cited 2019 Mar 25];1:148-50. Available from: http://www.ihji.org/text.asp?2018/1/2/148/247457




  Introduction Top


The complications during percutaneous coronary intervention (PCI) are rare but can have serious implications. Among the PCI complications, degloving and distortion of coronary stent is very rare, and the retrieval of such stent may sometimes require femoral arteriotomy or crushing of stent along the coronary artery wall. We describe such rare case of partially degloved and distorted coronary stent removal by novel improvised technique.


  Case Report Top


A 51-year-old male patient with diabetes was admitted in the peripheral hospital with a history of chest discomfort since midnight and diagnosed as a case of acute anterior wall myocardial infarction (AWMI). After giving loading doses of clopidogrel, aspirin, and statin, the patient was referred to our hospital for primary PCI.

After counseling, the patient was taken to catheterization lab as acute AWMI with q right bundle branch block with left ventricular ejection fraction of 30%. Diagnostic coronary angiography performed via right femoral artery through a 6F sheath using Cordis 6F (M/s Cordis De Mexico S.A), Judkins Left and Judkins Right catheter revealed 100% proximal left anterior descending (LAD) thrombotic stenosis with 80% proximal left circumflex and 90% distal right coronary artery stenosis [Figure 1]. We proceeded to perform primary PCI of LAD immediately with 6F-guiding catheter and Rinato 0.014ʺ (ASAHI INTECC CO LTD, Thailand) wire. After thrombosuction, as the LAD was flowing well with thrombolysis in myocardial infarction score II flow with two tandem proximal LAD lesions, we tried to stent the lesions with 3×33mm ProNOVA stent (Vascular concepts limited, Bangalore, Karnataka, India); however, the stent could not cross the second lesion and while manipulating and pulling it back into the guide, the guide got sucked into the LAD and hit the edge of the stent and the stent got partially degloved as well as distorted [Figure 2].
Figure 1: Angiogram in right anterior oblique caudal view showing proximal LAD 100% occluded

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Figure 2: Partially degloved coronary stent in proximal LAD

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The guidewire and partially degloved stent were withdrawn as a unit toward the sheath up to the descending aorta [Figure 3]. Now the challenge was to remove the stent through 6F femoral sheath. In the past, when we tried to remove such partially degloved stents through the smaller sized sheath, we had landed up with arteriotomy of femoral artery. This time, we kept the guidewire with stent into descending aorta and removed the 6F guide from the sheath. The distal end of stent was cut with scalpel to facilitate the smooth removal of 6F guide [Figure 4]. Later, we exchanged the 6F femoral sheath by 11F over the cut stent shaft and 0.014ʺ guidewire. We dilated the track with 11F dilator, and 11F sheath along with dilator was advanced over the distal end of cut shaft and 0.014ʺ percutaneous transluminal coronary angioplasty wire. And finally, the partially degloved stent was withdrawn along with guidewire as a unit smoothly into the 11F femoral sheath [Figure 5]. Later, a 0.32ʺ wire was inserted through the 11F sheath, and the degloved stent with 0.014ʺ wire and 11F sheath were removed as a unit [Figure 6] and [Figure 7]. Finally, the 11F sheath was reintroduced and PCI was completed. This case report highlights the technical feasibility of removing a partially degloved and distorted stent by a novel improvised technique.
Figure 3: Degloved stent in descending aorta along with wire and guide

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Figure 4: Separated distal end of stent from the shaft

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Figure 5: Degloved stent removed through the 11F sheath

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Figure 6: Passage of 0.032ʺ wire through the 11F sheath

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Figure 7: Partially degloved stent

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  Discussion Top


Complications during PCI include coronary artery complications (perforation, distal embolization, side branch occlusion, and stent thrombosis) and vascular complications (puncture site hematoma, retroperitoneal bleeding, and atheroembolism). Among them, stent entrapment with resulting stent deployment failure is rare but can cause fatal conditions such as stent thrombosis or myocardial infarction. Entrapment of coronary angioplasty devices, especially the stent, is rare but is a serious complication of PCI for which cardiac surgery is sometimes required. Calcified, long lesions and angulated lesions may predispose to the entrapment of the stent. The incidence of stent loss during PCI is reported to be only 0.32%, yet it is associated with an increased risk of complications.[1],[2] To prevent stent dislodgement or migration, predilatation with a balloon catheter or use of stents with a smaller profile and good trackability is recommended in case of severe angulated or calcified lesions.[3] In our case, we did not dilate the lesion after thrombosuction as we expected it to be thrombotic occlusion of proximal LAD and expected balloon dilatation to cause further slow flow or no flow with its associated complications.

A variety of stent retrieval methods have been described in the literature, such as using a snare device, a multipurpose basket, a variety of forceps, an angioguard (a distal protection device), a simple balloon, and just crushing of the stent into the vessel wall by a balloon.[4],[5],[6],[7]

In this case, we pulled out the stent and guiding catheter together to the iliac bifurcation level. After that, we exchanged the 6F femoral sheath by 11F. Then, we pulled the guidewire along with the partially degloved stent into the 11F sheath. Later, a 0.32ʺ wire was passed through the 11F femoral sheath. Finally, the 0.014ʺ guidewire, degloved stent, and 11F femoral sheath were removed as a unit. We think that this technique is easier and safer than other methods in this situation to prevent stent loss and embolization.

However, to avoid serious complications, interventional cardiologists should keep in mind the various complications during PCI and should understand the anatomy and characteristics of lesion in their daily practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brilakis ES, Best PJ, Elesber AA, Barsness GW, Lennon RJ, Holmes DR Jr, et al. Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention: A large single-center experience. Catheter Cardiovasc Interv 2005;1:333-40.  Back to cited text no. 1
    
2.
Eggebrecht H, Haude M, von Birgelen C, Oldenburg O, Baumgart D, Herrmann J, et al. Nonsurgical retrieval of embolized coronary stents. Catheter Cardiovasc Interv 2000;1:432-40.  Back to cited text no. 2
    
3.
Feldman T. Tricks for overcoming difficult stent delivery. Catheter Cardiovasc Interv 1999;1:285-6.  Back to cited text no. 3
    
4.
Foster-Smith KW, Garratt KN, Higano ST, Holmes DR Jr. Retrieval techniques for managing flexible intracoronary stent misplacement. Cathet Cardiovasc Diagn 1993;1:63-8.  Back to cited text no. 4
    
5.
Eeckhout E, Stauffer JC, Goy JJ. Retrieval of a migrated coronary stent by means of an alligator forceps catheter. Cathet Cardiovasc Diagn 1993;1:166-8.  Back to cited text no. 5
    
6.
Kim MH, Cha KS, Kim JS. Retrieval of dislodged and disfigured transradially delivered coronary stent: Report on a case using forcep and antegrade brachial sheath insertion. Catheter Cardiovasc Interv 2001;1:489-91.  Back to cited text no. 6
    
7.
Berder V, Bedossa M, Gras D, Paillard F, Le Breton H, Pony JC. Retrieval of a lost coronary stent from the descending aorta using a PTCA balloon and biopsy forceps. Cathet Cardiovasc Diagn 1993;1:351-3.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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