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TCTAP C-131 Entanglement of Embolized Undeployed Stent with Underdeployed Coronary Stent and Its Successful Management
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. This case demonstrates the crucial importance of lesion preparation with the aim to achieve almost stent-like result before final stent placement.This preparation includes use of noncompliant balloon, scoring balloons or cutting balloons and in some case debulking techniques to reduce the problems of incomplete stent delivery or stent lost. To take in consideration also the usage of catheter extension systems to avoid such stent lost. Extreme importance should be taken to have wide range of appropriate devices to face the most frequent complications. TCTAP C-131 Entanglement of Embolized Undeployed Stent with Underdeployed Coronary Stent and Its Successful Management Nishant Gangil,1 Madhav Menon,1 Christopher Nunn,1 Cherian Sebastian1 1 Waikato Hospital, New Zealand [CLINICAL INFORMATION] Patient initials or identifier number. DA Relevant clinical history and physical exam. A 50 year old very active gentleman with no coronary risk factors presented with Non ST Elevation Myocardial Infarction. His TIMI risk score was 2/7. He had no previous cardiac history. He was non diabetic, non hypertensive and non smoker. Physical examination unremarkable with normal cardiac and chest auscultation. Chest pain resolved with nitrates and low molecular weight heparin. He loaded on dual antiplatelets and underwent coronary angiogram the very next day. Relevant test results prior to catheterization. Electrocardiogram showed dynamic ST-T changes in lateral leads. Serial Troponin I showed rising trend from 70 to >1400 mIU/L. His complete blood picture was normal. Chest X Ray showed no evidence of cardiomegaly or fluid overload. Echocardiogram showed no regional wall motion abnormalities with good left ventricular systolic function. Normal renal parameters. Relevant catheterization findings. Coronary angiogram was done through right radial artery access. Left main coronary normal. Left circumflex (LCx) dominant sytem with proximal 90% stenosis. First Obtuse marginal branch had ostial 40% disease. RCA non dominat small vessel with proximal total occlusion. Decision to intervene percutaneously was made. Fractional flow reserve to mid LAD positive at 0.76. Successful angioplasty to LAD done with 3.5 x 24 mm drug eluting stent. [INTERVENTIONAL MANAGEMENT] Procedural step. Predilation of proximal circumflex (LCx) lesion with 3.0 mm balloon led to downstream spiral dissection in main LCx and 1st obtuse marginal branch leading to acute vessel closure. Patient had severe chest pain with ST elevation. Main circumflex stented with 3 drug-eluting stents in an overlapping fashion starting distally up to proximal LCx. TIMI3 flow was restored in LCx but 1st OM had no flow due to ostial dissection. OM recrossed using hydrophilic tapered wire and TIMI 3 flow restored after ballooning. Decided to do reverse crush bifurcation stenting but could not manage to pass stent into OM even after multiple attempts. Due to poor guide support through radial approach, we changed to femoral access. Next angiogram showed embolized un deployed stent in left main shaft which probably slipped off balloon while entering into OM through radial route.
S219
S220
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Urea : 7.7 mmol/L Potassium : 4.0 mmol/L Sodium : 139 mmol/L Creatinine : umol/L Liver Function Test Albumin : 29 g/L Alanine Aminotransferase : 10 U/L Alkaline Phosphatase : 71 U/L Coagulation Profile PT : 10.2 S INR : 1.0 APTT : 25.2 S ECG : Sinus rhythm, no ST, T or Q wave changes Exercise Stress Test : Positive METS Achieved : 12 ST segment depression noted at V3 To V6 Relevant catheterization findings
Next injection pushed stent into circumflex artery near proximal stent. Multiple attempts to snare the stent were made. Distal end of the stent was caught in the under deployed struts of proximal circumflex stent. On pulling the stent with snare, it unraveled on itself forming a long thin thread extending from LCx into left main.After, failure to snare, we pushed stent thread with 2.0 mm balloon into circumflex completely. LCx recrossed with wire and stent crushed into vessel wall with 3.0 mm balloon. Multiple attempts to pass IVUS failed. So LCx ostium stented with 4.0 mm DES plastering embolized stent into vessel wall. Excellent final result. Case Summary. Patient made excellent recovery. On follow up after 1 month, patient was asymptomatic with complete restoration of his lifestyle He advised to have long term dual antiplatelet therapy. Hardware should never be pushed against resistance. In this case it led to stent slipping off the balloon. Every lab should be equipped with various types of snares which prove handy in times of emergency. Interventionists should always be ready with alternate plan. Patience and presence of mind are the hallmark of good interventionist.
TCTAP C-132 The Adventurous Journey of Dislodge Stent Nor Halwani Habizal,1 Muhamad Ali SK Abdul Kader2 Hospital Pulau Pinang, Malaysia; 2Penang General Hospital, Penang Island, Malaysia 1
[CLINICAL INFORMATION] Patient initials or identifier number. MR P Relevant clinical history and physical exam. A 57 years-old, smoker with underlying diabetes mellitus, hypertension, dyslipidemia, was presented with one episode of generalized central chest pain and discomfort. It was not associated with nausea, vomiting, profuse sweating or syncope. There was no symptoms of heart failure. Has a family history of ischemic heart disease. The physical examinations were unremarkable. Relevant test results prior to catheterization. Full Blood Count WBC : 6.9 x 103 Hemoglobin : 11.6g/dl Platelet : 213 Renal Function Test
[INTERVENTIONAL MANAGEMENT] Procedural step. Right radial artery punctured and 6Fr sheath introduced. EBU 3.5 6Fr guide catheter engaged to left main (LM). Estimated of 52 mm significant lesion was recognized in LCX artery and our strategy to deploy and overlap using two stents. LCX artery was wired with Run through NS without difficulty. Distal lesion predilated with Sprinter Legend 2.0 x 20 at 14 atm and stent Terumo Ultimaster 2.5 x 28 at 12 atm deployed. The second stent for the proximal lesion, Terumo Ultimaster 3.0 x 24 introduced and unfortunately slipped from its balloon at the LM. Small Mini trek balloon 1.2 x 8 deployed distal to the stent and attempted to pull into the guider but failed. Another Mini trek balloon 2.0 x 8 deployed distal to the stent. Initially the stent was able to pull from the LM but unable to withdraw into the guider due to flawed stent. We were decided to pull out the balloon-stent-guider together into the right radial artery 6Fr sheath but failed. Subsequently, right femoral artery 14Fr sheath inserted and Mullin 10Fr sheath advanced into ascending aorta. Then the stent retrogradely pushed using MPA 1 5Fr but failed. Next, EBU 6Fr guide used to push back the stent into the Mullin sheath. The stent withdrawn together with the sheath successfully.
Case Summary. This case demonstrates the crucial importance of lesion preparation with the aim to achieve almost stent-like result before final stent placement.This preparation includes use of noncompliant balloon, scoring balloons or cutting balloons and in some case debulking techniques to reduce the problems of incomplete stent delivery or stent lost. To take in consideration also the usage of catheter extension systems to avoid such stent lost. Extreme importance should be taken to have wide range of appropriate devices to face the most frequent complications. TCTAP C-131 Entanglement of Embolized Undeployed Stent with Underdeployed Coronary Stent and Its Successful Management Nishant Gangil,1 Madhav Menon,1 Christopher Nunn,1 Cherian Sebastian1 1 Waikato Hospital, New Zealand [CLINICAL INFORMATION] Patient initials or identifier number. DA Relevant clinical history and physical exam. A 50 year old very active gentleman with no coronary risk factors presented with Non ST Elevation Myocardial Infarction. His TIMI risk score was 2/7. He had no previous cardiac history. He was non diabetic, non hypertensive and non smoker. Physical examination unremarkable with normal cardiac and chest auscultation. Chest pain resolved with nitrates and low molecular weight heparin. He loaded on dual antiplatelets and underwent coronary angiogram the very next day. Relevant test results prior to catheterization. Electrocardiogram showed dynamic ST-T changes in lateral leads. Serial Troponin I showed rising trend from 70 to >1400 mIU/L. His complete blood picture was normal. Chest X Ray showed no evidence of cardiomegaly or fluid overload. Echocardiogram showed no regional wall motion abnormalities with good left ventricular systolic function. Normal renal parameters. Relevant catheterization findings. Coronary angiogram was done through right radial artery access. Left main coronary normal. Left circumflex (LCx) dominant sytem with proximal 90% stenosis. First Obtuse marginal branch had ostial 40% disease. RCA non dominat small vessel with proximal total occlusion. Decision to intervene percutaneously was made. Fractional flow reserve to mid LAD positive at 0.76. Successful angioplasty to LAD done with 3.5 x 24 mm drug eluting stent. [INTERVENTIONAL MANAGEMENT] Procedural step. Predilation of proximal circumflex (LCx) lesion with 3.0 mm balloon led to downstream spiral dissection in main LCx and 1st obtuse marginal branch leading to acute vessel closure. Patient had severe chest pain with ST elevation. Main circumflex stented with 3 drug-eluting stents in an overlapping fashion starting distally up to proximal LCx. TIMI3 flow was restored in LCx but 1st OM had no flow due to ostial dissection. OM recrossed using hydrophilic tapered wire and TIMI 3 flow restored after ballooning. Decided to do reverse crush bifurcation stenting but could not manage to pass stent into OM even after multiple attempts. Due to poor guide support through radial approach, we changed to femoral access. Next angiogram showed embolized un deployed stent in left main shaft which probably slipped off balloon while entering into OM through radial route.
S219
S220
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Urea : 7.7 mmol/L Potassium : 4.0 mmol/L Sodium : 139 mmol/L Creatinine : umol/L Liver Function Test Albumin : 29 g/L Alanine Aminotransferase : 10 U/L Alkaline Phosphatase : 71 U/L Coagulation Profile PT : 10.2 S INR : 1.0 APTT : 25.2 S ECG : Sinus rhythm, no ST, T or Q wave changes Exercise Stress Test : Positive METS Achieved : 12 ST segment depression noted at V3 To V6 Relevant catheterization findings
Next injection pushed stent into circumflex artery near proximal stent. Multiple attempts to snare the stent were made. Distal end of the stent was caught in the under deployed struts of proximal circumflex stent. On pulling the stent with snare, it unraveled on itself forming a long thin thread extending from LCx into left main.After, failure to snare, we pushed stent thread with 2.0 mm balloon into circumflex completely. LCx recrossed with wire and stent crushed into vessel wall with 3.0 mm balloon. Multiple attempts to pass IVUS failed. So LCx ostium stented with 4.0 mm DES plastering embolized stent into vessel wall. Excellent final result. Case Summary. Patient made excellent recovery. On follow up after 1 month, patient was asymptomatic with complete restoration of his lifestyle He advised to have long term dual antiplatelet therapy. Hardware should never be pushed against resistance. In this case it led to stent slipping off the balloon. Every lab should be equipped with various types of snares which prove handy in times of emergency. Interventionists should always be ready with alternate plan. Patience and presence of mind are the hallmark of good interventionist.
TCTAP C-132 The Adventurous Journey of Dislodge Stent Nor Halwani Habizal,1 Muhamad Ali SK Abdul Kader2 Hospital Pulau Pinang, Malaysia; 2Penang General Hospital, Penang Island, Malaysia 1
[CLINICAL INFORMATION] Patient initials or identifier number. MR P Relevant clinical history and physical exam. A 57 years-old, smoker with underlying diabetes mellitus, hypertension, dyslipidemia, was presented with one episode of generalized central chest pain and discomfort. It was not associated with nausea, vomiting, profuse sweating or syncope. There was no symptoms of heart failure. Has a family history of ischemic heart disease. The physical examinations were unremarkable. Relevant test results prior to catheterization. Full Blood Count WBC : 6.9 x 103 Hemoglobin : 11.6g/dl Platelet : 213 Renal Function Test
[INTERVENTIONAL MANAGEMENT] Procedural step. Right radial artery punctured and 6Fr sheath introduced. EBU 3.5 6Fr guide catheter engaged to left main (LM). Estimated of 52 mm significant lesion was recognized in LCX artery and our strategy to deploy and overlap using two stents. LCX artery was wired with Run through NS without difficulty. Distal lesion predilated with Sprinter Legend 2.0 x 20 at 14 atm and stent Terumo Ultimaster 2.5 x 28 at 12 atm deployed. The second stent for the proximal lesion, Terumo Ultimaster 3.0 x 24 introduced and unfortunately slipped from its balloon at the LM. Small Mini trek balloon 1.2 x 8 deployed distal to the stent and attempted to pull into the guider but failed. Another Mini trek balloon 2.0 x 8 deployed distal to the stent. Initially the stent was able to pull from the LM but unable to withdraw into the guider due to flawed stent. We were decided to pull out the balloon-stent-guider together into the right radial artery 6Fr sheath but failed. Subsequently, right femoral artery 14Fr sheath inserted and Mullin 10Fr sheath advanced into ascending aorta. Then the stent retrogradely pushed using MPA 1 5Fr but failed. Next, EBU 6Fr guide used to push back the stent into the Mullin sheath. The stent withdrawn together with the sheath successfully.