Complications of Stent Loss during Treatment of a Heavily Calcified and Tortuous Chronic Total Occlusion Percutaneous Coronary Intervention
Presenter
Spyridon Kostantinis, MD, Minneapolis Heart Institute Foundation, Minneapolis, MN
Spyridon Kostantinis, MD1, Judit Karacsonyi, MD, PhD2, Bahadir Simsek, MD2 and Emmanouil S. Brilakis, MD, PhD, FSCAI2, (1)Minneapolis Heart Institute Foundation, Minneapolis, MN, (2)Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN
Title
Complications of Stent Loss during Treatment of a Heavily Calcified and Tortuous Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction
Stent loss is an uncommon but potentially life-threatening PCI complication. Coronary calcification and tortuosity are the most common angiographic characteristics associated with stent loss. Poor vessel preparation prior to attempting stent delivery as well as forceful or failed stent withdrawal into the guide catheter may predispose to stent loss. We present a chronic total occlusion (CTO) PCI complicated by stent loss, in which stent retrieval attempts resulted in coronary perforation.
Clinical Case
A 72-year-old-man who underwent coronary artery by-pass graft surgery 19 years prior presented with non-ST segment elevation acute myocardial infarction (NSTEMI) due to recurrent failure of a saphenous vein graft (SVG) supplying the first obtuse marginal branch (OM1). Angiography showed 60-70% in-stent stenosis within the previously placed proximal SVG to OM stents.
We aimed to recanalize the native OM1. Antegrade wiring with a Turnpike LP microcatheter and a Sion Blue and Fielder XT-A guidewire failed due to proximal cap ambiguity. A Venture catheter, a Turnpike LP microcatheter and various guidewires were used for retrograde crossing but failed too. Because of severe stenosis and calcification of the circumflex, a 3.0 x 15 mm AngioSculpt balloon was inflated in the proximal circumflex facilitating the advancement of a retrograde Gladius Mongo into the antegrade guide catheter, using the reverse controlled antegrade and retrograde tracking (reverse CART). Placement of two drug eluting stents (DES) restored antegrade flow into the OM1. Due to significant competitive blood flow between the SVG and OM1, decision was made to occlude the SVG using a 6 mm Amplatzer vascular plug. Repeat angiography showed a significant stenosis proximal to the SVG to OM1 distal anastomosis. Delivery of a 2.75 x 18 mm stent failed and the stent came off the balloon. The small balloon technique was used in an attempt to retrieve the lost stent, but it failed. Crushing of the stent with a 3.0 x 20 mm balloon was performed with additional lesion predilation. A 2.75 x 15 mm DES was deployed successfully. However, the previously crushed stent migrated distally. A 2-4 mm Ensnare was used in an attempt to retrieve the stent, but removal failed due to severe resistance to stent withdrawal. Coronary angiography revealed a large vessel perforation. A 3.0 x 15mm PK Papyrus stent covered the lost stent and sealed the perforation.
Discussion
Stent loss is an uncommon, but potentially serious PCI complication. Stent retrieval is often attempted if the stent is located in a potentially critical location, but may result in additional complications, such as coronary perforation. The most common retrieval technique is the “small balloon” technique. Stent deployment or crushing may be preferable to retrieval in many cases of stent loss as it may be the most time-efficient and low-risk strategy. When crushing a lost stent, covering it with an additional stent may help prevent migration of the lost stent.