SIMPLE STEMI – Not "ACCORDION" to Plan
Presenter
Kumar Sanam, MD, FSCAI, Cardiovascular Consultants Heart Center, Fresno, CA
Kumar Sanam, MD, FSCAI, Cardiovascular Consultants Heart Center, Fresno, CA, Rama Hritani, MD, Medical College of Georgia, Augusta, GA, Deepak Kapoor, M.D., Augusta University Medical Center, Augusta, GA and Kimberly Atianzar, M.D., FSCAI, Los Angeles County+USC Medical Center, Augusta, GA
Keywords: Atherectomy, Complex and High-risk Coronary Intervention (CHIP), Complications, Coronary and Left Main and Bifurcation
Title:
Simple STEMI? - Not 'Accordion' To Plan
Introduction:
Stent deformation is a rare complication of percutaneous coronary intervention with 0.3% incidence. We present a case of Stent “Accordion” deformation & migration requiring stent ablation with rotational atherectomy (RA) in a ST elevation myocardial infarction (STEMI) patient.
Clinical Case:
60 year old male presented with anterior STEMI with TIMI 0 flow in the proximal to mid left anterior descending (p-mLAD) artery. Using a 6F EBU 3.5 guide catheter & 6F guide extension, LAD was revascularized with 2 overlapping drug eluting stents (DES). Noncompliant balloon was used for post-DES dilatation & immediately removed. Angiography showed no reflow & pLAD stent accordion migration to distal left main (dLM) & LAD ostium. Patient became hypotensive requiring pressor support. Multiple balloon crossing & snare attempt of the accordion stent were unsuccessful. A microcatheter successfully burrowed into the stent for RotaFloppy wire exchange followed by successful RA stent ablation of the migrated stent. DES was deployed to the dLM & pLAD overlapped with mLAD stent. However, the accordion stent remnants migrated to the left circumflex (LCx) ostium with TIMI 0. A Mongo wire was able to cross the LCx, followed by compliant balloon dilatation & DES. Double kissing crush technique was be used for the bifurcating dLM-pLAD & LCx DES. Final angiographic images showed TIMI 2 LAD & TIMI 3 LCx flow, & improved hemodynamics as patient weaned off pressors.
Discussion:
Extensive literature review confirms this as the first reported STEMI stent “accordion” deformation & migration treated with RA. Severe calcification, pLAD stent underexpansion, guide extension &/or post-dilatation may have contributed to stent deformation & migration. Management typically involves stent retrieval w/ small balloon or snare, stent entrapment or crushing. Stent entrapment or crushing is the preferred approach due to quicker implementation. RA was challenging due to TIMI 0 LAD flow but assisted w/ stent material removal via thermal metal erosion to facilitate balloon expansion. This case demonstrates that RA stent ablation is feasible when conventional methods are unsuccessful, especially in an emergent situation.