Retrieval of undeployed stents from the right coronary artery: report of two cases

Innovative Guide Extension Catheter Trapping Technique to Retrieve a Lost Stent From a Coronary Artery

A stent that was being implanted in the left circumflex artery, to treat an iatrogenic dissection, became dislodged at the ostial left circumflex artery on a previously deployed stent implanted for the treatment of a distal left main bifurcation stenosis. We describe here a novel technique to retrieve the device safely. (Level of Difficulty: Advanced.)

Surgical retrieval of an entrapped stent and a stuck snare device during percutaneous coronary intervention

A 69-year-old male patient with a history of percutaneous coronary intervention (PCI) to the proximal left anterior descending coronary artery (LAD) underwent another PCI to the stenosis of the medium LAD as part of therapy for angina pectoris. Interruption of stent delivery because of past stent led to stent entrapment and a stuck guidewire. A snare catheter device was applied to retrieve the stent; however, the device lost mobility. Surgical removal and coronary artery bypass grafting (CABG) were required. We herein report some surgical techniques for resolving this complication of PCI. <Learning objective: Despite the recent advancements in devices and/or technical skills, the complications of PCI will never be eliminated. This case report provides a suggestive lesson with regard to open heart surgery for PCI complication; furthermore, only a few reports have described details concerning these PCI complications from the viewpoint of a surgeon. Physicians and surgeons should learn the emergent surgical techniques for resolving PCI complications.>.

How should I treat stent dislodgement in a STEMI patient resulting in dissection of left main and left circumflex arteries?

BACKGROUND

A 52-year-old female presented with acute anterior ST-elevation myocardial infarction (STEMI) within one hour of symptom onset to the emergency department. She was referred for urgent primary angioplasty.

INVESTIGATION

Physical examination, laboratory investigations, ECG, urgent percutaneous coronary intervention (PCI).

DIAGNOSIS

Single-vessel coronary artery disease (SVD).

TREATMENT

Intended to stent culprit lesion. However, stent dislodged in left main coronary artery (LMCA) during attempted PCI to diffuse mid segment of left anterior descending (LAD). Initial attempt failed to retrieve the dislodged stent with snare. Dislodged stent removed with multiple wire technique, complicated by severe dissection in LAD and left circumflex artery back into the LMCA. The stent was trapped at tip of 6 Fr right femoral sheath, unable to be withdrawn. What next?

Complications of coronary intervention: device embolisation, no-reflow, air embolism

The introduction of drug-eluting stents, better equipment, stronger antiplatelet drugs, and higher levels of operator experience has led to markedly improved patency rates for complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate complications. However, rigorous preventive measures pre-empt the appearance of complications. During traversal of severely diseased coronary arteries and manipulating equipment, particularly devices with detachable components, the opportunity for loss or embolisation of material in the coronary circulation presents itself. Device embolisation is associated with periprocedural myocardial infarction and emergent referral to surgery, particularly if the device is not retrieved. The coronary no-reflow phenomenon is a feared complication of PCI. It is associated with a worse prognosis and has been shown to be an independent predictor of death, myocardial infarction and impaired left ventricular function. Air embolism can be prevented by flushing of catheters during equipment exchanges.

Retrieval of dislodged coronary stent from left renal artery by gooseneck snare

A rapamycin-eluting stent was dislodged during attempt of implantation at the proximal right coronary artery, which was found by fluoroscopy to have migrated into the anterior trunk of the left renal artery. We chose a 5 mm diameter Amplatz gooseneck snare and successfully retrieved the lost stent from the lodging vessel.

Successful coronary stent retrieval from a pedal artery

The purpose of this article is to report complications from a coronary drug-eluting stent lost in the peripheral circulation. We report the case of successful retrieval of a sirolimus coronary stent from a pedal artery in a young patient who underwent coronary angiography for previous anterior myocardial infarction. Recognition of stent embolization requires adequate removal of the device to avoid unwelcome clinical sequelae.

Incidence, retrieval methods, and outcomes of stent loss during percutaneous coronary intervention: a large single-center experience

Our goal was to examine the incidence and consequences of stent loss during percutaneous coronary intervention (PCI) and the retrieval techniques used. We retrospectively reviewed 11,773 consecutive PCI cases involving stents performed at our institution between January 1994 and March 2004 to identify cases of stent loss. Stent loss occurred in 38 of 11,773 PCI procedures involving stents (0.32%; 95% CI = 0.23-0.44%). Mean age of the patients was 67 +/- 11 years and 82% were men. Stent loss occurred more frequently in lesions with calcification and/or significant proximal angulation. In three patients, the stent was crushed and covered with another stent without attempting retrieval. Stent retrieval was attempted in 35 of 38 cases and was successful in 30 (86%). The following retrieval methods were used (more than one method was used in some cases): advancing a balloon through the stent, inflating the balloon, and withdrawing the stent (45%); twirling two wires around the stent (5%); loop snare (26%); biliary forceps (12%); Cook retained fragment retriever (10%); and basket retrieval device (2%). Patients in whom stent loss occurred had a higher incidence of bleeding requiring transfusion (24% vs. 7%; P < 0.001) and more often required emergency coronary artery bypass surgery (5% vs. 0.4%; P < 0.001). No patients in whom the stent was crushed or deployed in the coronary artery had any major cardiac complication. Stent loss during PCI occurs infrequently. Lost stents can be successfully retrieved in the majority of cases using a variety of retrieval techniques, yet stent loss is associated with an increased risk of complications. Stent deployment or crushing may be a good alternative to retrieval.

Embolised stent into the circumflex coronary artery during percutaneous coronary intervention

Dislodgement and embolisation of the new generation of coronary stents before deployment are rare. If it is impossible to withdraw the embolised stent from the coronary artery, the stent may be crushed into the side wall of the coronary artery with a balloon over a wire passed alongside the embolised stent.

Intracoronary stent dislodgment: updated strategy enabled by the new generation of materials

Stent dislodgment remains a vexing problem in percutaneous coronary intervention. The technological improvements in machine-crimped premounted stents have led to a reduced incidence of dislodgment but may have exacerbated the problem of stent dislodgment (SD). Previous reports describing the management of SD have concentrated predominantly on manually mounted stents. We present a case where the position of a dislodged premounted stent in the distal left main stem was unfavorable for previously described solutions. The problem was elegantly resolved by taking advantage of the improved performance of the current generation of wires and balloons to achieve a rapid first-rate clinical outcome.

Percutaneous techniques for managing maldeployed or migrated stents

PURPOSE

To report our experience in the percutaneous management of dislocated endovascular stents.

METHODS

During a 6-year period, 28 (2.7%) patients with a maldeployed or migrated endovascular stent (20 Palmaz, 5 Wallstent, 2 Memotherm, and 1 AVE) were recognized among 1021 patients undergoing noncardiac vascular stent procedures. Percutaneous stent management was performed using balloon catheters, gooseneck snares, grasping forceps, or additional stent implantation on the basis of the stent type, degree of expansion, mechanical characteristics, and location of the stent.

RESULTS

Three stents that embolized into the pulmonary artery were left in situ, but percutaneous management was successful in 23 (92%) of the remaining 25 dislocated stents (12 venous and 13 arterial stents). Twelve stents were repositioned in an alternate, stable position or the primarily intended location; 4 stents were anchored by a second stent, and 7 stents were removed percutaneously. In the 2 failed cases, the stents were retrieved using a minor surgical procedure. There were 2 minor groin hematomas but no secondary complications during a median follow-up of 26.2 months (range 1-62).

CONCLUSIONS

Percutaneous management of migrated or maldeployed endovascular stents is highly effective with few complications. On the basis of our findings, these techniques should be considered the therapy of choice.

Nonsurgical retrieval of embolized coronary stents

Embolization of coronary stents before deployment is a rare but challenging complication of coronary stenting. Different methods for nonsurgical stent retrieval have been suggested. There were 20 cases (0.90%) of intracoronary stent embolization among 2,211 patients who underwent implantation of 4,066 stents. Twelve of 1,147 manually crimped stents (1.04%) and eight of 2,919 premounted stents were lost (0.27%, P < 0.01) during retraction of the delivery system, because the target lesion could not be either reached or crossed. Percutaneous retrieval was successfully carried out in 10 of 14 patients (71%) in whom retrieval was attempted. In 10 patients, stent retrieval was tried with 1.5-mm low-profile angioplasty balloon catheters (success in 7/10) and in seven cases with myocardial biopsy forceps or a gooseneck snare (success in 3/7). Three patients (15%) underwent urgent coronary artery bypass surgery after failed percutaneous retrieval, but their outcomes were fatal. In two patients, stents were compressed against the vessel wall by another stent, without compromising coronary blood flow. In two patients, a stent was lost to the periphery without clinical side effects; treatment was conservative in these cases. Embolization of stents before deployment is a rare but serious complication of coronary stenting, with hazardous potential for the patient. Manual mounting of stents is associated with a significantly higher risk of stent embolization. Stent retrieval from the coronary circulation with low-profile angioplasty balloon catheters is a readily available and technically familiar approach that has a relatively high success rate.

An unusual mechanism of coronary stent dislodgment and localization

Stent dislodgment from its delivery catheter is a rare yet clinically important entity in cardiac catheterization. We report a highly unusual case of stent loss and subsequent localization in the guiding catheter. Our hypothesized mechanism of stent dislodgment should be recognized by the medical community.

Facilitation of stent retention and retrieval with an emboli containment device

A potential consequence of unsuccessful stent delivery is dislodgment of the stent from the delivery catheter resulting in embolization. Recently, an angioplasty guidewire incorporating a distal occlusion balloon (GuardWire) has become available. We describe how, when used for the prevention of distal embolization of atheromatous or thrombotic particles, this device may facilitate retention and retrieval of undeployed stents.

A technique to retrieve stents dislodged in the coronary artery followed by fixation in the iliac artery by means of balloon angioplasty and peripheral stent deployment

An unwelcome complication of the increasingly applied technique of coronary stenting is stent dislodgment, which may cause arterial occlusion or distal embolization, both with potentially adverse sequel. Stent dislodgment tends to occur when negotiating a tortuous artery with a balloon-mounted stent, especially if the artery is irregularly calcified or when applying a rigid stent. We have successfully applied in several patients at our laboratory a technique to retrieve a dislodged stent from the coronary artery, tow it to the iliac artery, and then deploy it locally by a peripheral balloon when retrieval through the vascular sheath seems impossible. Finally, the retrieved stent is secured by local anchoring with a peripheral stent. This technique was found to be useful and may prevent further complications and more costly interventions and hence result in a more benign clinical course. Cathet. Cardiovasc. Intervent. 49:77-81, 2000.

Management of misplaced or migrated endovascular stents

PURPOSE

To report experience with techniques for management of misplaced or migrated endovascular stents.

MATERIALS AND METHODS

During a 5-year period, percutaneous management of 27 misplaced or migrated endovascular stents (16 Palmaz, 11 Wallstents) in 25 patients was attempted. The 17 venous and 10 arterial stents were rescued from the aorta (n = 9), inferior vena cava (IVC) (n = 4), transjugular intrahepatic portosystemic shunt/IVC (n = 2), right atrium (n = 3), right ventricle (n = 2), pulmonary artery (n = 2), iliac vein (n = 2), iliac artery (n = 1), superior vena cava (n = 1), and superior mesenteric vein (n = 1).

RESULTS

Stent management was successful in 26 of 27 cases (96%). Eleven stents were removed percutaneously, two were repositioned and removed with a minor surgical procedure, and 13 were repositioned and deployed in a stable alternate location. The only complication was the development of tricuspid insufficiency in the single case in which the procedure failed (4% complication rate). This patient's stent was eventually surgically removed from the right ventricle.

CONCLUSION

Misplaced or migrated endovascular Palmaz and Wallstents can be effectively managed with few complications by using a variety of percutaneous techniques.

Mechanisms, management, and outcome of failure of delivery of coronary stents

In a single-center experience, initial failure of attempted stent delivery was relatively infrequent (2.7%) but was associated with increased need for urgent coronary bypass surgery. Delivery failure was more likely with coiled stents and dislodgment from the delivery balloon was more likely with hand-mounted or radiolucent stents.

Unexpanded, irretrievable stent in the proximal right coronary artery: successful management with stent graft implantation

Stent loss and failure of retrieval are rare; nevertheless, complications have to be taken into account during percutaneous coronary intervention. Here we report a case of an unexpanded, irretrievable Palmaz-Schatz stent in the proximal right coronary artery near to the ostium and the successful management by implanting a synthetic stent graft.

New method for placement of intracoronary stents in order to avoid their embolization in the intravascular space

Stent dislodgment from the delivery catheter is a well-known complication of angioplasty with stent implantation. The aim of our study was to investigate the feasibility, effectiveness, and safety of a new technique of intracoronary stent implantation in order to avoid stent loss in the intravascular space. Fifty consecutive patients were candidates for angioplasty and stent placement. During angioplasty, a technique was followed according to which the guide wire "hindered" the dislodgment of the stent from the balloon catheter. Successful angioplasty and stent placement were performed in 46 out of 50 patients (92% success rate). In three cases of failure of stent implantation, the stent moved onto the balloon catheter; however, this was impeded by the guide wire. One non-Q-wave myocardial infarction occurred. No major complications (Q-wave myocardial infarction, CABG, or death) were observed. In conclusion, the technique applied was feasible enough, safe, and effective. However, the appropriate modification of its "hardware" will render it even more feasible and user-friendly.

Therapeutic repositioning of a Gianturco-Roubin II coronary stent after initial deployment

Movement of coronary stents after deployment can produce complications. We report a case of stent migration that led to stent coverage of a distal dissection, obviating the need for placement of a second stent. In this case, stent movement was therapeutic.

Successful management of Palmaz-Schatz stents deformed by inadvertent angioplasty outside the stents

We describe a case in which balloon angioplasty of thrombosed saphenous vein graft stents resulted in compression and deformation of the stents because of inadvertent passage of the guidewire outside the stents. This condition was diagnosed by intravascular ultrasonography, which was then ultimately utilized to direct and optimize placement of additional stents to exclude the deformed stents from the vessel lumen.

Intracoronary loss of balloon-mounted stents: successful retrieval with a 2 mm-"Microsnare"-device

Intracoronary loss of balloon-mounted stents prior to deployment is a rare event but may result in clinically relevant cardiac ischemia or peripheral embolization during rescue attempts. In a consecutive series of nearly 400 patients undergoing elective stenting, we encountered six instances of intracoronary misplacement. We describe four cases of successful percutaneous retrieval using a 2 mm closed loop nitinol device ("Microsnare"). Our proposed method of extraction seems to hold advantages over those previously described.

Contemporary stent designs: technical considerations, complications, role of intravascular ultrasound, and anticoagulation therapy

A number of studies have shown the benefits of stent placement over balloon angioplasty for the treatment of focal, native coronary artery, and saphenous vein graft disease. Although the number of stent designs available for clinical use has increased dramatically, the late clinical benefit of stenting over balloon angioplasty has yet to be shown in diffuse disease, complex bifurcation stenoses, or smaller (2.5-mm) vessels, each of which may require unique stent designs and adjunct therapies not currently available or extensively studied. The purposes of this review are to discuss the various stent designs currently available for clinical use, outline the known complications associated with these stents, assess the contribution of intravascular ultrasound, and describe current antiplatelet and antithrombotic therapy used after stent use.

Extraction of fully deployed coronary stents

Coronary stents are often used because of their potential to improve the acute and long-term results of balloon angioplasty. The Palmaz-Schatz stent has been approved for use by the U.S. Food and Drug Administration largely because of a demonstrated reduction in the incidence of restenosis following its primary implantation. The Gianturco-Roubin design has been approved for use when balloon angioplasty results in threatened or acute vessel closure. In practice, both stent types are being used in settings when the results of balloon angioplasty are either potentially or actually unacceptable. In such circumstances it is imperative that stents be placed accurately and carefully. Occasionally, stent misplacement, embolization, or disruption can occur, and the need arises to recover and/or reposition the wayward prosthesis. This review describes the removal and recovery of fully deployed Gianturco-Roubin stents using an intracoronary snare technique.

Successful retrieval of unexpanded Palmaz-Schatz stent from left main coronary artery

A 64-year-old patient with silent myocardial ischemia after anterior myocardial infarction was treated with directional coronary atherectomy, balloon angioplasty, and placement of Palmaz-Schatz stent. An unexpanded Palmaz-Schatz stent was retained in the left main coronary artery and was treated successfully with a nitinol goose-neck snare. After this procedure, another Palmaz-Schatz stent was successfully implanted without any complications.

Thrombotic occlusion of the coronary artery associated with accidental detachment of undeployed Palmaz-Schatz stent

We describe a case of coronary stenting in which accidental detachment of the Palmaz-Schatz stent induced thrombotic occlusion of the coronary artery. This case suggests that careful consideration of the risk involving coronary occlusion is mandatory on deciding the therapeutic strategy of the cases in which the unexpanded coronary stent cannot be retrieved following successful deployment.

Retrieval of undeployed intracoronary Palmaz-Schatz stents

Two patients undergoing stent placement with the Palmaz-Schatz coronary stent delivery system experienced intracoronary stent embolization. Using a two-wire technique, the stents were successfully removed from the coronary circulation, and this allowed completion of the percutaneous revascularization procedure without any clinical sequelae. These two cases represent the first report of successful percutaneous retrieval of undeployed, retained intracoronary Palmaz-Schatz stents.

Retrieval of occluding unexpanded Palmaz-Schatz stent from a saphenous aorto-coronary vein graft

The Palmaz-Schatz coronary stent is used frequently to reduce the rate of restenosis of balloon angioplasty in saphenous vein grafts. In many European centers, the stent, manually crimped on a balloon, is advanced across the stenosis without a protective sheath. This report describes a patient in whom an attempt to deploy a stent in the orifice of a saphenous vein graft was complicated by dislodgement of the unexpanded stent from the balloon. The unexpanded stent caused immediate occlusion of the vein graft and severe ischemic symptoms. The stent was retrieved by inflation of another balloon in the graft, distal to the stent, pulling the balloon toward the guiding catheter, and then withdrawing the whole system.

Successful transcatheter management of Palmaz Stent embolization after superior vena cava stenting

A 34-year-old patient with benign superior vena cava syndrome (SVCS) was treated with thrombolytic therapy, balloon angioplasty, and placement of two peripheral Palmaz stents. Embolization of one stent to the right atrium occurred 10 min after successful implantation. This serious complication was successfully managed by percutaneous transcatheter technique with retrieval from the right atrium and subsequent deployment into the right external iliac vein of the lost stent. Complete resolution of SVCS symptoms occurred within 24 hr and moderate superior vena cava restenosis was successfully dilated 8 months later. At 12-month follow-up the patient continues to be asymptomatic.