Lost and found: Coronary stent retrieval and review of literature

Diagnosis of Coronary Stent Dislodgement With Transthoracic Echocardiogram: A Case Report

Coronary stent dislodgment is a rare complication of percutaneous coronary intervention (PCI). Although stent dislodgment typically occurs immediately in the intraoperative or perioperative period, it can infrequently occur subacutely in the post-operative period. Diagnosis of stent dislodgment can be seen with various cardiac imaging modalities, from transthoracic and transesophageal echocardiogram to cardiac computed tomography or magnetic resonance imaging to direct visualization on fluoroscopy during cardiac catheterization. Given the rarity of this entity, there is a lack of established common practice, gold standard for treatment, and/or procedural data. Instances are managed on a case-by-case basis, using the imaging modalities readily available at the institution and treatment modalities the interventionalist or surgeon is most comfortable with. Therefore, management of stent dislodgment consists of conservative, percutaneous, or surgical interventions on a case-by-case basis. We present a case of right coronary artery stent migration that was incidentally diagnosed with routine transthoracic echocardiogram.

A Challenging Case of Stent Dislodgement During Percutaneous Coronary Intervention Complicated by Peripheral Embolization

We report a challenging case of stent dislodgement for a 49-year-old male with a history of end-stage renal disease and insulin-dependent diabetes undergoing an elective coronary angiogram for cardiac risk stratification before kidney transplant surgery. A diagnostic transradial coronary angiogram was performed showing two severe type A lesions to the proximal and distal left circumflex artery (LCx). While attempting to stent the proximal LCx, the stent dislodged to the left main coronary artery (LMCA). The stent was successfully retrieved from the LMCA via the transradial route using the small balloon anchoring technique. Unfortunately, while attempting to retrieve the stent-balloon assembly, the stent was accidentally stripped off the balloon embolizing to the right superior gluteal artery. Given the stable location, no attempt was made to retrieve the stent and the patient had no complications on follow-up. This case highlights the challenges in managing coronary stent loss including risk factors for stent dislodgement, methods to retrieve the stent, and the risk of stent embolization.

Stent embolization in stented segment: a diagnostic challenge

ABSTRACT

Stent dislodgement during angioplasty is a rare but potentially fatal complication if not properly managed. We described a case of an elderly man who had previously undergone coronary angioplasty and now presented with an inferior wall myocardial infarction and required emergency angioplasty. Because of the loss of antegrade flow during the procedure, the proximal lesion was stented first. Undeployed stent was dislodged into proximal stent during distal stent deployment through proximal stent. This complication was addressed by crushing the undeployed stent and deploying another stent to secure the crushed stent to the arterial wall. Postprocedure patient was stable and discharged after 2 days. An operator should be aware of this risk as well as possible bailout options.

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.)

When Things Get Stuck: Gear Entrapment and Other Complications of Chronic Total Occlusion Percutaneous Coronary Intervention

Complex coronary artery intervention stresses the limits of both the operator's skills as well as the equipment being used for the procedure. This article is focused on avoiding, recognizing and dealing with device failure and gear entrapment during complex coronary intervention. The operator must understand how to avoid these complications by understanding the limits of devices and the need for adequate vessel preparation. This article focuses on giving the reader an algorithmic approach to recognizing when device failure/entrapment occurs and what specific maneuvers can be done to retrieve different devices and equipment safely.

Effects and mechanisms of glucose-insulin-potassium on post-procedural myocardial injury after percutaneous coronary intervention

OBJECTIVE

To evaluate the effects and mechanisms of glucose-insulin-potassium (GIK) on post-procedural myocardial injury (PMI) after percutaneous coronary intervention (PCI).

METHODS

A total of 200 non-diabetic patients with documented coronary heart disease (CHD) were divided into the Group GIK and Group G, with 100 patients in each group. Patients in Group G were given intravenous infusion of glucose solution 2 hours before PCI. As compared, patients in Group GIK were given GIK.

RESULTS

Both post-procedural creatine phosphokinase isoenzyme MB (CK-MB; 62.1 ± 47.8 vs. 48.8 ± 52.6 U/L, P = 0.007) and cTnI (0.68 ± 0.83 vs. 0.19 ± 0.24 ng/mL, P < 0.001) in Group GIK were significantly higher than those in Group G. In Group G, 9.0% and 4.0% of patients had post-procedural increases in CK-MB 1-3 times and > 3 times, which were significantly lower than those in Group GIK (14.0% and 7.0%, respectively; all P values < 0.01); 13.0% and 7.0% of patients had post-procedural increases in cTnI 1-3 times and > 3 times, which were also significantly lower than those in Group GIK (21.0% and 13.0%, respectively; all P < 0.001). Pre-procedural (10.2 ± 4.5 vs. 5.1 ± 6.3, P < 0.001) and post-procedural rapid blood glucose (RBG) levels (8.9 ± 3.9 vs. 5.3 ± 5.6, P < 0.001) in Group G were higher than those in Group GIK. In adjusted logistic models, usage of GIK (compared with glucose solution) remained significantly and independently associated with higher risk of post-procedural increases in both CK-MB and cTnI levels > 3 times. Furthermore, pre-procedural RBG levels < 5.0mmol/L were significantly associated with higher risk of post-procedural increases in both CK-MB and cTnI levels.

CONCLUSIONS

In non-diabetic patients with CHD, the administration of GIK may increase the risk of PMI due to hypoglycemia induced by GIK.

Successful percutaneous retrieval of a detached microcatheter tip using the guide-extension catheter trapping technique: A case report

A 55-year-old male with stable angina pectoris was referred to our hospital. Coronary angiography showed severe stenosis from the proximal to the middle part of the left circumflex artery (LCX). Based on the severity of lesion calcification, we performed percutaneous coronary intervention with rotational atherectomy. After crossing a 0.014-inch guidewire, we replaced it with a rotawire using a microcatheter. Following the retrieval of the microcatheter, we noted that a radiopaque tip of the microcatheter had been detached at the site of severe stenosis in the proximal part of the LCX. We advanced a guide-extension catheter to this site and wedged the detached tip using a balloon catheter (2.0-mm diameter; 12-mm length) in the guide-extension catheter. The detached tip was successfully retrieved along with the guide-extension catheter. After passing two guidewires into the main vessel and the side branch, we dilated the lesion using a 2.5-mm non-compliant balloon. Finally, we implanted two sirolimus-eluting stents, followed by post-dilatation with a 3.75-mm non-compliant balloon. This approach resulted in excellent dilatation and blood flow. Use of the guide-extension catheter trapping technique (i.e. use of a guide-extension catheter and a small balloon catheter) resulted in the successful percutaneous retrieval of a detached microcatheter tip. <Learning objective: We occasionally encounter adverse events related to the detachment or breakage of devices when performing percutaneous coronary intervention. The guide-extension catheter trapping technique using a guide-extension catheter and a small balloon is a useful approach for the retrieval of dislodged or entrapped devices.>.

Usefulness of the twin guidewire method during retrieval of the broken tip of a microcatheter entrapped in a heavily calcified coronary artery

During percutaneous coronary intervention performed for a stenotic lesion with heavy calcification in the left coronary artery, the microcatheter tip became transected in the vessel. The fragment was successfully retrieved using the twin guidewire method after negotiating to cross a chronic total occlusion-dedicated guidewire outside the retained tip.