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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 3  |  Page : 109-113  

Right coronary artery stent dislodgment during primary percutaneous coronary intervention. To leave or to retrieve?


Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Fahad Abdullah Al Kindi
Department of Cardiology, Heart Hospital, Hamad Medical Corporation, PO Box: 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_74_19

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   Abstract 


Coronary stent dislodgment and embolization are rare and challenging complications of percutaneous coronary intervention that may result in serious and fatal complications attributed to the loss of blood flow of the coronary, cerebral, or peripheral circulations. Percutaneous management is successful in most cases using different techniques and devices, but surgery may be required. We report two cases of stent dislodgment during primary PCI for the right coronary artery with different management approaches and outcomes.

Keywords: Coronary stent dislodgment, percutaneous coronary intervention, stent retrieval


How to cite this article:
Al Kindi DI, Al Kindi FA. Right coronary artery stent dislodgment during primary percutaneous coronary intervention. To leave or to retrieve?. Heart Views 2019;20:109-13

How to cite this URL:
Al Kindi DI, Al Kindi FA. Right coronary artery stent dislodgment during primary percutaneous coronary intervention. To leave or to retrieve?. Heart Views [serial online] 2019 [cited 2019 Oct 15];20:109-13. Available from: http://www.heartviews.org/text.asp?2019/20/3/109/267849




   Introduction Top


Coronary stents play a vital role in the management of acute occlusive coronary artery disease. Stents have increased the safety and revascularization success rate which led to the improvement in clinical outcomes ultimately.[1]

Coronary stent loss or embolization is a rare and challenging complication of PCI, with a reported incidence ranging from 0.21% to 8.4%.[2] It can lead to acute myocardial infarction, emergency coronary artery bypass graft, stroke, and death.[2],[3],[4] Stent loss is dislodgmnet of the stent inside the body at a location different than the intended delivery location.

We report two cases of stent loss which occurred during primary PCI of the right coronary artery (RCA). Management of stent loss with different approaches and literature review is included.

Case 1

A 53-year-old male smoker admitted with inferoposterior ST-elevation myocardial infarction. Coronary angiography on admission revealed 100% proximal RCA thrombotic occlusion. PCI to the proximal RCA was done with two overlapping bare-metal stents (Liberté 4.0 mm × 32 mm and Multi-Link RX Vision 4.0 mm × 12 mm). During implantation of the stent in the proximal RCA lesion, the patient moved suddenly and took a deep breath that led to the displacement of almost one-third (proximal part) of the stent into the ascending aorta which was left without retrieval attempt as per the operator decision [Figure 1].
Figure 1: Right coronary angiography showing the proximal part of the stent hanging in the ascending aorta (white arrow) and the right coronary artery ostium (black arrowhead)

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Five months later, the patient was brought to the hospital with a history of collapse preceded by severe chest pain and sweating. He was in cardiogenic shock with a blood pressure of 60/30 mmHg and hence initiated on saline and noradrenaline infusion. The electrocardiography (ECG) revealed ST-segment elevation in inferior leads. Posterior wall and right ventricular infraction were suggested by the posterior and right-side ECG. He was loaded with 300 mg aspirin and 600 mg clopidogrel and was transferred to catheterization laboratory. 6-Fr Judkins right type 4 (JR4) guide catheter was used. Angiography revealed stent thrombosis from the RCA ostium [Figure 2]. There were many difficulties encountered in the management of this patient. Due to the patient restlessness and his status of cardiogenic shock, he was intubated. As the previous stent was displaced into the ascending aorta, it was very difficult to engage the guide catheter inside the stent entrance.
Figure 2: Angiography of the right coronary artery showing stent thrombosis. Initial attempts to engage the right coronary artery failed due to the previous stent dislodgment to the ascending aorta

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The guidewire was passed through the upper stent struts, and then, a small compliant balloon (Trek 2.5 mm × 15 mm) was inflated to open an entry through the struts into the RCA which gave a room to perform angioplasty. Angiography revealed ostial/proximal thrombus. Another 80% distal stenosis was noted with no distal flow [Figure 3].
Figure 3: Angiography of the right coronary artery after passing the guidewire and catheter engagement through the upper side of the old stent struts showing proximal stenosis and 80% distal right coronary artery stenosis

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For the proximal RCA lesion, thrombus aspiration was initially done, and then, drug-eluting balloon (IN. Pact Falcon 3.5 mm × 30 mm) was inflated at the pressure of 14 ATM for a total of 66 s. Thrombolysis in myocardial infarction (TIMI) 3 flow was achieved after the procedure. For the distal RCA stenosis, it was predilated, and then, DES Xience PRO X 3.5 mm × 12 mm was used with good final results [Figure 4]. No complications occurred during the hospital stay, and the patient was discharged in good condition.
Figure 4: Angiography of the right coronary artery after percutaneous coronary intervention

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Case 2

A 31-year-old male with a past medical history of hypertension and smoking presented to the hospital with typical chest pain. Admission ECG showed a sinus rhythm and ST-segment elevation in leads II, III, aVF, V5, and V6. He emergently underwent coronary angiography via the right femoral artery through 6-F femoral sheath which revealed a mid and distal 80% stenosis of the RCA [Figure 5]. Apart from 50% stenosis in the first diagonal branch, the left system was normal.
Figure 5: Angiography of the right coronary artery demonstrating the original stenosis in the mid and distal right coronary artery

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During angiography, the patient was restless and in pain; so, he was sedated with midazolam and was given fentanyl as a pain killer.

PCI was attempted for the mid-RCA lesion initially. A 6-Fr JR4 guide catheter was used to advance the guidewire, and then, the lesion was predilated.

A drug-eluting stent (Xience Sierra 3.5/38 mm) was advanced to the mid-RCA lesion. During stent deployment, the patient snored and took a deep breath which resulted in stent dislodgment. Fortunately, this action was noticed by the operator and immediately aborted stent inflation and full deployment. The result was stent dislodgment hanging between RCA ostium and ascending aorta partially deployed [Figure 6].
Figure 6: Angiography of the right coronary artery demonstrating the stent partially deployed in ostial right coronary artery (black arrowhead) and the rest of the stent in the ascending aorta (white arrow)

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Since about two-third of the stent was dislodged into the aorta, we decided that the best management is to retrieve the stent by means of Gooseneck Snare System which successfully retrieved the stent [Figure 7] and [Figure 8].
Figure 7: Angiography at the descending aorta showing the dislodged stent (white arrow) captured by the snare (arrowhead)

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Figure 8: Stent retrieved with Goose snare into the guide catheter

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There was no damage to the RCA noted after stent retrieval. PCI was done to the middle and distal RCA with overlapping 2 DES (3.5 × 38 mm/Resolute Ony × 3.5 × 12 mm). A TIMI flow grade 3 achieved post-PCI [Figure 9]. The patient was discharged in a stable condition and was followed up in the outpatient clinic.
Figure 9: Angiography of the right coronary artery post percutaneous coronary intervention with thrombolysis in myocardial infarction 3 flow

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   Discussion Top


With the advancement in the newer generation stents' quality and improved experience in PCI, stent loss became a rare complication with the estimated incidence 0.21%–8.4%.[2],[3],[4] In most cases of stent loss, percutaneous management is successful.[2],[3],[4],[5],[6],[7] Although it is uncommon nowadays, it is associated with serious complications including acute myocardial infarction, embolic cerebrovascular events, the need for emergency coronary artery bypass graft, bleeding requiring transfusion, and death.[2],[3],[4]

In most studies, stent loss occurred more commonly in the RCA, elderly patients (around 60 years of age or older), male gender, patients with one or more coronary artery disease risk factors, and patients with previous coronary artery event or intervention.[2],[3],[4],[5]

There are several factors that lead to stent loss which could be related to patients, vessel characteristics, or to the procedure. The most common causes are heavy classifications, severe tortuosity, and significant proximal angulation.[2],[3],[5] Other vessels factors are long, distal lesions and lesions located in previous stents (in-stent restenosis). On the other hand, procedure-related factors include direct stenting, use of small size stents, inadequate pre dilatation, inadequate guidewire or guide catheter support, and stent deformity for any reason.[2],[3],[4],[5],[6]

However, in both our cases, the reason for stent dislodgement was related to the patients as both were restless and making movements during angiography and that coincide at the time of stent. Another factor is the ostial location of the lesion which makes stent dislodge easily to the ascending aorta. Moreover, the catheter used is JR4 which has poor support.

Most of the cases are successfully managed via percutaneous approach,[2],[3],[4],[5],[6],[7] whereas surgical intervention is required mainly if the stent embolizes and causes coronary occlusion leading to hemodynamic instability.[3] Nevertheless, peripheral stent loss rarely causes complications, and in many cases, it cannot be localized.[5],[6]

The management decision is made on the view of stent location, stent distortion, deployment status, operator experience, and the presence of complications. Percutaneous management options are stent retrieval, deployment, or crushing with another stent.

Percutaneous stent retrieval can be done with different techniques. The most common and successful technique is by using a snare which consists of a loop advanced through a delivery catheter and the stent is captured between them.[2],[8],[10],[11] There are several types of snares (single loop or multiple loops and in several diameters) enabling effective stent retrieval. In some occasions where the commercial snare kit is not available, improvised snares can be made utilizing available materials in the catheterization laboratory.[12] The other common method is the small balloon technique which can be used only if the guidewire is maintained through the lost stent where a small balloon is advanced through the stent, inflated, and then withdrawn together with the lost stent.[2],[6],[7] Other retrieval methods include the two-wire technique, the hairpin-wire technique, and other devices such as forceps, cook fragment retriever, and basket.[2],[3] Stent deployment or crushing with another stent is an alternative safe and successful management option with favorable outcomes, taking in consideration the stent location and deployment feasibility.[3],[4],[5] These methods might be attempted before retrieval in patients who had stent embolization without complications.[5]

In some instances, the lost stent is left without the attempt of retrieval, but it carries the risk of vascular occlusion, leading to myocardial infarction and the need for re-intervention.[9]

In our first case, in the first presentation of inferior ST-elevation myocardial infarction (STEMI), the stent dislodgment to the ascending aorta was noticed only after full deployment which made stent retrieval difficult with a high possibility of artery damage and complications. Hence, the decision was made to leave the stent and advise the patient to be compliant with antiplatelet therapy. Despite patient compliance with medications, 5 months later, he came with inferior STEMI due to ostial stent thrombosis. As the previous stent was dislodged in the ascending aorta, the guide catheter engagement was extremely difficult. In addition to that, the patient was restless and hypotensive, for which he was intubated. These factors prolonged the time to reperfusion and required multiple trials to engage the RCA and proceed with percutaneous angioplasty.

In the second case, the stent was dislodged and partially deployed hanging between the ascending aorta and RCA. Gooseneck snare was available, but there was length mismatch between the snare and the delivery catheter which was solved by cutting about 15 cm from the delivery catheter tip. Eventually, snaring of the stent was successful, and then, PCI was done to both RCA lesions.

Given the fact that ostial or proximal RCA lesions are more likely associated with stent loss, careful attention should be made during PCI. We recommend to make sure that the patient is not making movements or taking a deep breath during stent deployment and to use a strong support catheter for difficult cases.

Due to a high risk of serious complications of stent loss either in short or long term, we advise to retrieve any lost stent when feasible.


   Conclusion Top


Stent dislodgment and loss are rare nowadays, but the anticipation of such complication accompanied by careful and accurate stent deployment may prevent it. In such a situation, stent retrieval is advised. All catheterization laboratories should be equipped with proper retrieval instruments and interventional cardiologist to be familiar with percutaneous management of such complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Al Suwaidi J, Berger PB, Holmes DR Jr., Coronary artery stents. JAMA 2000;284:1828-36.  Back to cited text no. 1
    
2.
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;25:637-41.  Back to cited text no. 2
    
3.
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;66:333-40.  Back to cited text no. 3
    
4.
Nikolsky E, Gruberg L, Pechersky S, Kapeliovich M, Grenadier E, Amikam S, et al. Stent deployment failure: Reasons, implications, and short-and long-term outcomes. Catheter Cardiovasc Interv 2003;59:324-8.  Back to cited text no. 4
    
5.
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;48:129-36.  Back to cited text no. 5
    
6.
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;51:432-40.  Back to cited text no. 6
    
7.
Iturbe JM, Abdel-Karim AR, Papayannis A, Mahmood A, Rangan BV, Banerjee S, et al. Frequency, treatment, and consequences of device loss and entrapment in contemporary percutaneous coronary interventions. J Invasive Cardiol 2012;24:215-21.  Back to cited text no. 7
    
8.
Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49:281-5.  Back to cited text no. 8
    
9.
Shim BJ, Lee JM, Lee SJ, Kim SS, Lee DH, Shin WS, et al. Three cases of non-surgical treatment of stent loss during percutaneous coronary intervention. Korean Circ J 2010;40:530-5.  Back to cited text no. 9
    
10.
Yurtdas M, Aladag N, Yaylali Y. Successful transcatheter retrieval of the embolized coronary stent during primary percutaneous coronary intervention. J Med Cases 2016;7:417-9.  Back to cited text no. 10
    
11.
Jang JH, Woo SI, Yang DH, Park SD, Kim DH, Shin SH. Successful coronary stent retrieval from the ascending aorta using a gooseneck snare kit. Korean J Intern Med 2013;28:481-5.  Back to cited text no. 11
    
12.
Shewale R, Sharma A, Pagad S. A tale of two dislodged stents – Successful retrieval with limited hardware using indigenous snares. J Cardiovasc Dis Res 2018;9:99-102.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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