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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 161-165

A fortunate FEAST: Favorable embolization of an agile stent to the target vessel


1 Department of Cardiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
2 Department of Cardiology, Jaswant Rai Specialty Hospital, Meerut, India
3 Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Aditya Kapoor
Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_24_18

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  Abstract 

Dislodgement of coronary stents while performing coronary interventions is not an uncommon phenomenon. Although more frequently encountered with stents that were manually crimped, dislodgement can also occur with the newer generation, balloon-mounted stents despite their superior trackability and deliverability. We describe a case with severe right coronary artery (RCA) and obtuse marginal (OM) disease in which an initial coronary angioplasty to the RCA followed by OM was planned. The RCA was stented and while negotiating a second balloon-mounted stent across the RCA, it slipped off the balloon and initially embolized into the aortic sinuses. Subsequently and fortuitously, the stent migrated into the OM vessel and was seated right at the lesion, which needed to be stented. Using the clear cell stent boost function, the embolized stent was wired and then deployed using sequential balloon dilations.

Keywords: Coronary angioplasty, stent dislodgement, stent embolization


How to cite this article:
Senguttuvan NB, Agarwala R, Kapoor A. A fortunate FEAST: Favorable embolization of an agile stent to the target vessel. Indian Heart J Interv 2018;1:161-5

How to cite this URL:
Senguttuvan NB, Agarwala R, Kapoor A. A fortunate FEAST: Favorable embolization of an agile stent to the target vessel. Indian Heart J Interv [serial online] 2018 [cited 2019 Jul 21];1:161-5. Available from: http://www.ihji.org/text.asp?2018/1/2/161/247448




  Introduction Top


The use of coronary stents during percutaneous coronary intervention is now an established therapeutic modality in patients with coronary artery disease. Dislodgement and embolization of coronary stents, although rare, is a known but potentially lethal complication of angioplasty procedures.[1],[2],[3] Although manually crimped stents were associated with a higher risk, embolization is not uncommon with the balloon-mounted stents despite their superior trackability and deliverability. With increasingly complex coronary interventions being performed including those in tortuous, calcified, and long lesions, cases of dislodged coronary stents shall continue to intrigue the interventional cardiologists. Efforts need to be made to retrieve dislodged coronary stents (whether into the systemic or coronary circulation) to avoid arterial and target organ compromise, coronary thrombosis, myocardial infarction (MI), or even death.[4],[5] We report a case wherein a balloon-mounted stent peeled off from its balloon before deployment in the right coronary artery (RCA) and embolized into the aortic sinus followed by migration into the left circumflex system. Fortuitously, the stent embolized to the obtuse marginal (OM) that needed to be stented. Initial attempts to wire the stent revealed that the wire was on the side, rather than being intraluminal. Using the clear cell stent boost function, the wire and a balloon was placed through the lumen of the uninflated stent. Following this, the stent was deployed with sequential balloon dilatation using 2.0 and 3.0mm balloons with a final satisfactory result.


  Case Report Top


HL, a 55-year-old man, was admitted with inferior ST elevation MI. He was an ex-smoker and had no history of hypertension, diabetes, or old MI. Coronary angiography revealed no significant disease in the left anterior descending (LAD) artery with severe focal disease in the proximal part of major OM1 and 100% proximal occlusion in the RCA [Figure 1]A–[C]. A decision to perform angioplasty to the RCA followed by OM was taken, and accordingly, the RCA was cannulated using a 6F AR1 guide (Medtronic Launcher, Minneapolis, Minnesota). The lesion was crossed with great difficulty using a Hi-Torque Whisper extra support wire, 0.014×190 (Abbot Vascular International BVBA, Diegem, Belgium), followed by multiple dilatations using 2.0×10mm Sapphire balloon (OrbusNeich, Hoevelaken, The Netherlands) at 8 atm. The vessel wall at this stage showed a contained hematoma with dissection starting in the proximal RCA and extending beyond [Figure 2]A and [B], Video 1]. Further balloon dilatations were carried out, and the RCA lesion was stented using a 3×28mm stent (Cobalt Chromium Coronary Stent System [CE]; Sahajanand Laser Technology, Gujarat, India), which was deployed at 14 atm [[Figure 2]C, followed by post-dilatation using a noncompliant balloon (3.0×8.0mm, Sapphire NC Coronary Dilatation Catheter; OrbusNeich). After deployment of the stent, a residual lesion was noted at the distal edge of the deployed stent [Figure 2]D, and a 3×10mm stent (Cobalt Chromium Coronary stent system [CE]; Sahajanand Laser Technology) was used to cover this lesion.
Figure 1: Coronary angiogram showing no significant disease in the LAD with severe focal disease in the proximal part of major OM1 (A: RAO view, B: AP cranial view) and 100% proximal occlusion in the RCA (C: LAO view). RAO = right anterior oblique, LAO = left anterior oblique, AP = antero-posterior

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Figure 2: Proximal dissection with contained hematoma in the RCA (A and B) following first stent placement (C) and the residual lesion at the distal edge of the deployed stent (D)

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Stent dislodged at the ostium of RCA and finally drops into the aortic sinuses

While negotiating this stent across the previously deployed RCA stent, we noticed that the second stent had slipped off its balloon and had been dislodged at the ostium of the RCA. At this time, the guide catheter also got disengaged and the entire assembly including the angioplasty guide wire slipped out, with the stent being lodged at the ostium of the RCA [Figure 3]A, Video 2]. The dislodged stent subsequently migrated into the region of the aortic sinuses and was seen freely moving in that area [Video 3]. In the absence of a snare on shelf, an indigenous snare was created using 300cm × .014 HI-Torque BMW guide wire (Abbott Vascular International BVBA) through 6F JR4 RCA guiding catheter. Several attempts were made to snare the stent but were unsuccessful due to its extreme mobility because of aortic flow ejection. Suddenly the stent disappeared and was no longer visible in the region of the aortic sinus region.
Figure 3: Dislodged stent lying at the RCA ostium (A), the stent migrating to the OM (B), the clear cell boost function showing the wire and the balloon on the side of the stent and not intraluminal (C), and final correct placement of the wire through the stent using the clear cell boost function (D)

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A fortuitous embolization to the OM

Fearing embolization, we decided to screen the vascular tree to try and localize the dislodged stent. However, to our surprise, it was found that the stent had dislodged into the OM vessel and was seated right at the lesion, which was planned to be stented [[Figure 3]B, Video 4]. An extra-backup (EBU) 6F × 3.5 EBU Launcher guide catheter (Medtronic) was used to cannulate the left coronary artery, and the OM was wired using a 190cm × .014 Hi-Torque BMW guide wire (Abbott Vascular International BVBA). The plan was to pass a balloon through the uninflated stent and deploy it at the site of the lesion. A 2×10mm Sapphire balloon (OrbusNeich) was taken and we opted to use the clear cell boost function (Artis zee/zeego; Siemens, Erlangen, Germany) to observe if the balloon had indeed passed through the stent. Using this, it was clear that the wire and the balloon were on the side of the stent, rather than being intraluminal [[Figure 3]C, Video 5]. The OM was again rewired and the balloon was placed through the stent, using the stent boost function as a guide [[Figure 3]D, Video 6]. Following this, the stent was sequentially inflated (from distal to proximal) using a 2.0×10mm and 3×10mm Sapphire balloon (OrbusNeich) for 30s at 8 atm [[Figure 4]A and B]. The final result was satisfactory with TIMI 3 flow [[Figure 4]C, and the patient made an uneventful recovery with discharge at 48h.
Figure 4: Sequential inflation of the stent in OM from distal (A) to proximal (B) and final result (C)

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  Discussion Top


Dislodgement of coronary stents while performing coronary interventions is not uncommon, and the reported incidence varies from 1.5% to 8%.[1],[2],[3] The incidence of stent loss during coronary interventions has been decreasing with newer generation stents, better stent designs, and delivery systems, and current stent loss rates are reported to be approximately 0.3%–1%.[6] Although the incidence of stent dislodgement was higher in stents that needed to be manually crimped onto balloons, with the interventional cardiologists continuing to attempt more and more complex coronary interventions including tortuous, calcified, and long lesions, cases of dislodged coronary stents shall continue to occur even with the current generation of drug-eluting, balloon-mounted coronary stents.

Various factors influence the risk of stent dislodgement, including the underlying coronary anatomy, type of hardware used, as well as operator experience.[6] Tortuous, calcified, angulated, and long, diffuse lesions not only make it difficult to deliver the stent to the site of lesion but may also lead to excessive and undue manipulation of the stent delivery system, leading to deformation and dislodgement of the stent while withdrawing and retracting the stent delivery assembly.[7],[8] Lack of adequate guide support with poor backup; use of older generation stents with suboptimal trackability, flexibility, and poor radial strength; and operator skills also play a role in influencing rates of stent embolization.

Although all efforts should be made to retrieve dislodged stents, systemic (noncoronary) embolizations are reported to have a relatively benign course. In contrast, in cases with stents embolized to coronary arteries, the likelihood of an adverse event is nearly 10 times higher in case of nonretrieved stents as compared to when the stent is retrieved.[9],[10],[11]

Retrieval methods

Various percutaneous techniques have been described for the retrieval of dislodged coronary stents, and it is important that the practicing interventional cardiologists are familiar with these so that potentially catastrophic sequel of stent embolization can be minimized. These techniques include the use of gooseneck snares, basket devices, or myocardial biopsy forceps; the use of two parallel guide wires twisted together to entrap the dislodged stent; inflation of a small profile balloon distal to the undeployed stent with gradual withdrawal of the entire system; and compression and crushing of the dislodged stent against the vessel wall with another stent.[1],[2],[12-14] Occasionally, emergency coronary artery bypass surgery may be the only option in such cases. The type of retrieval technique used is often governed by the clinical status of the patient, any associated hemodynamic compromise, and operator familiarity with the various available retrieval options.

In our patient, the complication was perhaps related to the fact that the proximal RCA was slightly tortuous, and in an attempt to negotiate the second stent across the proximally deployed stent, use of excessive manipulation led to its slippage from the balloon. We were extremely fortunate that the stent migrated to the exact site of the lesion in the OM vessel that required stenting, thus obviating retrieval. Using the clear cell boost function, as described earlier, we deployed the stent at the site of the lesion.

Observing certain precautions can help reduce the rates of stent dislodgement, especially in complex coronary anatomy with angulated, calcified, and tortuous lesions. Adequate, sequential pre-dilatation and avoidance of direct coronary stenting in these lesion subsets; inadvertent pre-inflation of the balloon before stent deployment; and stenting the distal lesion first followed by stenting the proximal lesion (in cases with multiple lesions) are the key points to be kept in mind. In our case, it was felt that there was a residual lesion at the distal edge of the first stent, thus necessitating the deployment of the second stent through the proximally deployed stent. Most importantly, if at any time undue resistance is felt during the advancement of the stent delivery system, rather than using excessive force or manipulation, it is advisable to withdraw the entire assembly as a single unit.


  Conclusion Top


Stent dislodgement and embolization is an uncommon but potentially life-threatening complication, which can be encountered by all interventional cardiologists. Observing certain precautions, being familiar with various retrieval techniques, and availability of adequate retrieval hardware are mandatory to manage such cases when needed.

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
    
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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
    
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Alfonso F, Martinez D, Hernández R, Goicolea J, Segovia J, Fernández-Ortiz A, et al. Stent embolization during intracoronary stenting. Am J Cardiol 1996;1:833-5.  Back to cited text no. 3
    
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Colombo A, Maiello L, Almagor Y, Thomas J, Zerboni S, Di Summa M, et al. Coronary stenting: Single institution experience with the initial 100 cases using the Palmaz-Schatz stent. Cathet Cardiovasc Diagn 1992;1:171-6.  Back to cited text no. 4
    
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Elsner M, Peifer A, Kasper W. Intracoronary loss of balloon-mounted stents: Successful retrieval with a 2 mm-“Microsnare”-device. Cathet Cardiovasc Diagn 1996;1:271-6.  Back to cited text no. 5
    
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Alomar ME, Michael TT, Patel VG, Altomare CG, Rangan BV, Cipher D, et al. Stent loss and retrieval during percutaneous coronary interventions: A systematic review and meta-analysis. J Invasive Cardiol 2013;1:637-41.  Back to cited text no. 6
    
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Holmes DR Jr, Garratt KN, Popma J. Stent complications. J Invasive Cardiol 1998;1:385-95.  Back to cited text no. 7
    
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Laarman G, Muthusamy TS, Swart H, Westendorp I, Kiemeneij F, Slagboom T, et al. Direct coronary stent implantation: Safety, feasibility, and predictors of success of the strategy of direct coronary stent implantation. Catheter Cardiovasc Interv 2001;1:443-8.  Back to cited text no. 8
    
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Colkesen AY, Baltali M, Acil T, Tekin G, Tekin A, Erol T, et al. Coronary and systemic stent embolization during percutaneous coronary interventions: A single center experience. Int Heart J 2007;1:129-36.  Back to cited text no. 9
    
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Bolte J, Neumann U, Pfafferott C, Vogt A, Engel HJ, Mehmel HC, et al.; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärtze (ALKK). Incidence, management, and outcome of stent loss during intracoronary stenting. Am J Cardiol 2001;1:565-7.  Back to cited text no. 10
    
11.
Kammler J, Leisch F, Kerschner K, Kypta A, Steinwender C, Kratochwill H, et al. Long-term follow-up in patients with lost coronary stents during interventional procedures. Am J Cardiol 2006;1:367-9.  Back to cited text no. 11
    
12.
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. 12
    
13.
Antonellis IP, Patsilnakos SP, Pamboukas CA, Kranidis AJ, Papadopoulos A, Margaris N, et al. Successful withdrawal from the right coronary artery of an NIR stent dislodged from the balloon catheter. J Interv Cardiol 1999;1:215-8.  Back to cited text no. 13
    
14.
Lyer SS, Rubin GS. Nonsurgical management of retained intracoronary stent following intervention. In: Rubin GS, editor. Interventional cardiovascular medicine. New York: Churchill Livingstone; 1994. pp. 635-41.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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