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TCTAP C-127 Retrieval of a Dislodged Coronary Stent
S246
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-127 Retrieval of a Dislodged Coronary Stent Kin Ming Tam1 1 Yan Chai Hospital, Hong Kong, China [CLINICAL INFORMATION] Patient initials or identifier number. Mr. K. M. WONG Relevant clinical history and physical exam. A 62 year-old gentleman with hyperlipidemia and smoking history suffered from Non ST elevation Myocardial Infarction in 7/2015. His blood tests showed elevated cardiac Troponin I, and normal renal and liver functions. Relevant test results prior to catheterization. Echocardiogram revealed anterior hypokinesia with satisfactory LV systolic function EF 60%; no significant valvular lesion was noted. Relevant catheterization findings. Elective coronary angiogram via right radial arterywith was performed in 9/2015: [Cine 01, 03 to 04] -Dominant Right Coronary Artery(RCA) tortuous course at mid part; mid RCA50% lesion -Left Main (LM) normal -Proximal Left Anterior Descending (LAD) ulcerative lesion with 50%stenosis; mid LAD 70-80% lesion; 2ndDiagonal (D2) 50%stenosis -Proximal Left Circumflex (LCx)70% stenosis; Obtuse Marginal (OM) 50%lesion Adhoc Percutaneous Coronary Intervention (PCI) was planned with stenting to LAD(mid to proximal part) followed by mid LCx lesions. [INTERVENTIONAL MANAGEMENT] Procedural step. 6 Fr EBU 3.5 via RRA was used to engage LM. 3.0/ 48 mm drug eluting stent (DES) was deployed at mid LAD and stenting at proximal LAD by a 3.5/22 mm DES with overlapping. Proximal LCx was stented with 2.75/22 mm DES. Chest pain occurred with ECG changes. Cine showed jailed D2. A new wire was sent to D2 with distal true lumen being confirmed by contrast injection via micro-catheter. Stenting of D2 by TAP approach was planned. Resistance was encountered in advancing a 2.25/26 mm DES to D2 at the level of proximal LAD stent. There was also difficulty in retrieving the stuck stent, and it was found dislodged. Strategies for retrieving dislodged stent were considered. A 6 Fr Judkins Left 4 (JL4) guiding catheter via RFA was placed at ostial LM and a new wire was sent down to LAD. The femoral guiding system allowed us to assess by IVUS the dislodged stent in relations to proximal LAD. In addition, this could also serve as a backup to LM-LAD stenting in case the coronary access through radial system was lost. Snaring by Amplatz Goose Neck Snares (2 and 4 mm) through radial system on D2 wire was attempted but unsuccessful. Finally, an EN Snare (9-15 mm) with three inter-laced loops was used, finally the dislodged stent was successfully caught and retrieved. A 3.0/18 mm DES was deployed from proximal LAD stent with overlapping back to LM ostium. Angiographic and IVUS result was satisfactory with TIMI 2 flow at D2 maintained.
Case Summary. Don’t panic. If guide wire position is lost, fast re-wiring of vessels is life saving. Heamostasis by dilatation of the in-situ balloon is the first line of management. Perfusion balloons, graft stents, coils, heamostatic agents are very useful tools. Advancement of operators experience and dealing with perforation nightmares increased the procedural success.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S247
TCTAP C-128 Acute Brachial Artery Thrombosis Associated with Heparin-induced Thrombocytopenia After Transradial Coronary Intervention Yisik Kim,1 Jei Keon Chae,1 Soo-Kyeong Song,1 Ji-Young Yoon,1 Laeyoung Jung,1 Sun-Hwa Lee,1 Sang-Rok Lee,1 Kyoung-Suk Rhee,1 Won-Ho Kim,1 Jae-Ki Ko1 1 Chonbuk National University Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. LOR, 1267524 Relevant clinical history and physical exam. A 74-year-old woman presented to the emergency room with chest discomfort and shortness of breath. She had no history of chronic medical illness. On admission, her blood pressure was 140/90 mmHg with a pulse of 88 beats per minute. Relevant test results prior to catheterization. The electrocardiography showed Q wave and T wave inversion in precordial leads. Chest x-ray showed pulmonary venous congestion on both lung fields. Transthoracic echocardiography (TTE) revealed an impaired LV ejection fraction by 33% and multiple RWMA. Cardiac troponin I (cTnI) was positive. She was diagnosed with non ST-elevation MI. Conventional medical therapy that include a loading dose of aspirin (300 mg), clopidogrel (600 mg) and unfractionated heparin was applied before PCI. Relevant catheterization findings. Coronary angiography (CAG) showed CTO of RCA and thrombotic near total occlusion of mid LAD. At first, PCI to LAD was performed with implantation of one drug eluting stent (DES) 3.028 mm (Xience XpeditionÒ , Abbott Vascular, USA) via right radial artery. After procedure, unfractionated heparin was continued with adequate therapeutic aPTT range and CTO-RCA was deferred for stage PCI.
Case Summary. In retrieving a dislodged stent, the mechanism of dislodgement, the presence of wire in the dislodged stent and the position of stent in relations to coronary arteries, aorta and guiding catheter were to be considered. We believed that a segment of diagonal wire went under stent strut at proximal LAD and therefore the new stent on diagonal wire was trapped with proximal LAD stent. Gripping force from trapping balloon inside guiding catheter failed to hold the deformed and elongated stent. Snares could provide strong pulling force but coronary snares failed also. EN Snare with interlaced loops finally caught the stent. We should have a emergency backup by setting up another guiding catheter.
[INTERVENTIONAL MANAGEMENT] Procedural step. On hospital day (HD) #4, the patient developed severe pain and discoloration on right first and second digits (Fig 2A). Physical examination revealed diminished right brachial and absent radial pulses. CT angiography revealed total occlusion of distal right brachial artery (Fig 2B). Emergent catheterization was performed through right femoral artery and angiography documented thrombotic total occlusion of the right brachial artery. Repetitive thrombectomy and trancatheter thrombolysis with urokinase was performed (Fig 3A). Next day, however, the pain and discoloration of digits was increasing, follow-up angiogram showed re-occlusion of right brachial artery (Fig 3B). We performed repetitive thrombus aspiration and balloon angioplasty (Fig 3C, 3D). Final angiogram showed improved distal run-off (Fig 3E) and we decided to continue unfractionated heparin therapy for 3 days. After PTA, the pulses were improved to near-normal and cyanosis was diminished. On HD #8, stage PCI to CTO-RCA was performed successfully via right femoral artery. However, after stage PCI, on HD #9, platelet count of 82 x x103 /mL was documented. Platelet count on admission was 219 x103 /m L. Because 4Ts score 7 suggested high probability of heparin-induced thrombocytopenia thrombosis (HIT/T), unfractionated heparin was discontinued and anticoagulation with fondaparinux was started. Platelet count was declined to 3.6 x103 /mL on HD #15.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-127 Retrieval of a Dislodged Coronary Stent Kin Ming Tam1 1 Yan Chai Hospital, Hong Kong, China [CLINICAL INFORMATION] Patient initials or identifier number. Mr. K. M. WONG Relevant clinical history and physical exam. A 62 year-old gentleman with hyperlipidemia and smoking history suffered from Non ST elevation Myocardial Infarction in 7/2015. His blood tests showed elevated cardiac Troponin I, and normal renal and liver functions. Relevant test results prior to catheterization. Echocardiogram revealed anterior hypokinesia with satisfactory LV systolic function EF 60%; no significant valvular lesion was noted. Relevant catheterization findings. Elective coronary angiogram via right radial arterywith was performed in 9/2015: [Cine 01, 03 to 04] -Dominant Right Coronary Artery(RCA) tortuous course at mid part; mid RCA50% lesion -Left Main (LM) normal -Proximal Left Anterior Descending (LAD) ulcerative lesion with 50%stenosis; mid LAD 70-80% lesion; 2ndDiagonal (D2) 50%stenosis -Proximal Left Circumflex (LCx)70% stenosis; Obtuse Marginal (OM) 50%lesion Adhoc Percutaneous Coronary Intervention (PCI) was planned with stenting to LAD(mid to proximal part) followed by mid LCx lesions. [INTERVENTIONAL MANAGEMENT] Procedural step. 6 Fr EBU 3.5 via RRA was used to engage LM. 3.0/ 48 mm drug eluting stent (DES) was deployed at mid LAD and stenting at proximal LAD by a 3.5/22 mm DES with overlapping. Proximal LCx was stented with 2.75/22 mm DES. Chest pain occurred with ECG changes. Cine showed jailed D2. A new wire was sent to D2 with distal true lumen being confirmed by contrast injection via micro-catheter. Stenting of D2 by TAP approach was planned. Resistance was encountered in advancing a 2.25/26 mm DES to D2 at the level of proximal LAD stent. There was also difficulty in retrieving the stuck stent, and it was found dislodged. Strategies for retrieving dislodged stent were considered. A 6 Fr Judkins Left 4 (JL4) guiding catheter via RFA was placed at ostial LM and a new wire was sent down to LAD. The femoral guiding system allowed us to assess by IVUS the dislodged stent in relations to proximal LAD. In addition, this could also serve as a backup to LM-LAD stenting in case the coronary access through radial system was lost. Snaring by Amplatz Goose Neck Snares (2 and 4 mm) through radial system on D2 wire was attempted but unsuccessful. Finally, an EN Snare (9-15 mm) with three inter-laced loops was used, finally the dislodged stent was successfully caught and retrieved. A 3.0/18 mm DES was deployed from proximal LAD stent with overlapping back to LM ostium. Angiographic and IVUS result was satisfactory with TIMI 2 flow at D2 maintained.
Case Summary. Don’t panic. If guide wire position is lost, fast re-wiring of vessels is life saving. Heamostasis by dilatation of the in-situ balloon is the first line of management. Perfusion balloons, graft stents, coils, heamostatic agents are very useful tools. Advancement of operators experience and dealing with perforation nightmares increased the procedural success.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S247
TCTAP C-128 Acute Brachial Artery Thrombosis Associated with Heparin-induced Thrombocytopenia After Transradial Coronary Intervention Yisik Kim,1 Jei Keon Chae,1 Soo-Kyeong Song,1 Ji-Young Yoon,1 Laeyoung Jung,1 Sun-Hwa Lee,1 Sang-Rok Lee,1 Kyoung-Suk Rhee,1 Won-Ho Kim,1 Jae-Ki Ko1 1 Chonbuk National University Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. LOR, 1267524 Relevant clinical history and physical exam. A 74-year-old woman presented to the emergency room with chest discomfort and shortness of breath. She had no history of chronic medical illness. On admission, her blood pressure was 140/90 mmHg with a pulse of 88 beats per minute. Relevant test results prior to catheterization. The electrocardiography showed Q wave and T wave inversion in precordial leads. Chest x-ray showed pulmonary venous congestion on both lung fields. Transthoracic echocardiography (TTE) revealed an impaired LV ejection fraction by 33% and multiple RWMA. Cardiac troponin I (cTnI) was positive. She was diagnosed with non ST-elevation MI. Conventional medical therapy that include a loading dose of aspirin (300 mg), clopidogrel (600 mg) and unfractionated heparin was applied before PCI. Relevant catheterization findings. Coronary angiography (CAG) showed CTO of RCA and thrombotic near total occlusion of mid LAD. At first, PCI to LAD was performed with implantation of one drug eluting stent (DES) 3.028 mm (Xience XpeditionÒ , Abbott Vascular, USA) via right radial artery. After procedure, unfractionated heparin was continued with adequate therapeutic aPTT range and CTO-RCA was deferred for stage PCI.
Case Summary. In retrieving a dislodged stent, the mechanism of dislodgement, the presence of wire in the dislodged stent and the position of stent in relations to coronary arteries, aorta and guiding catheter were to be considered. We believed that a segment of diagonal wire went under stent strut at proximal LAD and therefore the new stent on diagonal wire was trapped with proximal LAD stent. Gripping force from trapping balloon inside guiding catheter failed to hold the deformed and elongated stent. Snares could provide strong pulling force but coronary snares failed also. EN Snare with interlaced loops finally caught the stent. We should have a emergency backup by setting up another guiding catheter.
[INTERVENTIONAL MANAGEMENT] Procedural step. On hospital day (HD) #4, the patient developed severe pain and discoloration on right first and second digits (Fig 2A). Physical examination revealed diminished right brachial and absent radial pulses. CT angiography revealed total occlusion of distal right brachial artery (Fig 2B). Emergent catheterization was performed through right femoral artery and angiography documented thrombotic total occlusion of the right brachial artery. Repetitive thrombectomy and trancatheter thrombolysis with urokinase was performed (Fig 3A). Next day, however, the pain and discoloration of digits was increasing, follow-up angiogram showed re-occlusion of right brachial artery (Fig 3B). We performed repetitive thrombus aspiration and balloon angioplasty (Fig 3C, 3D). Final angiogram showed improved distal run-off (Fig 3E) and we decided to continue unfractionated heparin therapy for 3 days. After PTA, the pulses were improved to near-normal and cyanosis was diminished. On HD #8, stage PCI to CTO-RCA was performed successfully via right femoral artery. However, after stage PCI, on HD #9, platelet count of 82 x x103 /mL was documented. Platelet count on admission was 219 x103 /m L. Because 4Ts score 7 suggested high probability of heparin-induced thrombocytopenia thrombosis (HIT/T), unfractionated heparin was discontinued and anticoagulation with fondaparinux was started. Platelet count was declined to 3.6 x103 /mL on HD #15.