Two dislodged and crushed coronary stents: treatment of two simultaneously dislodged stents using crushing techniques
A 58-year-old female patient was admitted to the cardiology department due to a 7-day history of chest pain. She had hypertension but electrocardiography was normal and cardiac enzymes were in the normal range. Left coronary angiography performed via the left radial artery showed irregular significant tubal stenosis of the mid LAD, tubular 50% narrowing of the LM, severe stenosis of the ostial LAD, and narrowing of the ostial left circumflex coronary artery (). Right coronary angiography showed no significant narrowing of the right coronary artery (). We recommended off-pump coronary artery bypass (OPCAB) for the LAD lesion and we planned to undergo PCI in the LCX lesion after OPCAB. Five days later, she underwent OPCAB, in which anastomoses were formed of the left internal mammary artery (LIMA) to the first diagonal branch (D1), and the right internal mammary artery (RIMA) to the distal LAD. Seven days postoperatively, follow-up coronary angiography revealed intact graft flow from the RIMA to the distal LAD, (), but completely occluded graft flow from the LIMA to the D1 (). Therefore, PCI was planned for the LM, the ostial and mid LAD, and the ostial LCX. A 7 Fr extraback-up (EBU) guiding catheter (Medtronics, Santa Rosa, CA, USA) was engaged at the ostium of the LM. Runthrough wires (Termo, Tokyo, Japan) were placed in the distal LAD and LCX. Initially, a 3.0 × 15 mm Xience stent (Abbott Vascular, Santa Clara, CA, USA) was implanted in the mid LAD (). Using a 2.5 × 15 mm Ryujin balloon (Termo), ostial segments of the LCX and LAD were alternatively dilated. Next, we used minicrush techniques. First, a 2.5 × 12 mm Xience stent was positioned in the proximal LCX more distally and was then pulled back to the point that the proximal marker of the LCX stent contacted the body of the main vessel stent. A 3.5 × 23 mm Xience stent was then introduced into the distal LM to the proximal LAD to overlap the mid LAD stent. However, it could not be delivered to the target lesion despite multiple attempts to advance the stent distally. We felt that further aggressive dilation was required. When we attempted to retrieve the stents into the guide catheter, both stents simultaneously detached from the stent balloons and two guide wires were placed in the center of the stents (). We initially planned to retrieve the dislodged stent in the LM to the proximal LAD using a 5 mm Gooseneck snare (St. Jude Medical, Sylmar, CA, USA). After the stent was successfully snared, we retracted the snare without removing the whole system, because the other stent had dislodged in the LM to the ostial LCX. When we retracted the snare, the stent was distorted and elongated into the guide catheter, preventing withdrawal using the guide catheter. At that time the patient was stable, so we decided to remove the two dislodged stents surgically. When the entire system including the guide catheter and wires were removed, the stent remained from the LM to the ascending thoracic aorta (). Later the patient developed severe chest pain, which was followed by cardiogenic shock. Immediately, another 7 Fr EBU guiding catheter was engaged at the ostium of the LM and coronary angiography showed nearly total occlusion at the distal portion of the LM with thrombolysis in myocardial infarction 1 flow due to an intracoronary thrombus (). The ostial segment of the LAD was dilated using a 2.5 × 15 mm Ryujin balloon to 8 atmosphere (atm) and a new 3.5 × 23 mm Xience stent was introduced into the mid LM to the proximal LAD across the LCX lesion and deployed (), restoring the blood pressure to 125/75 mmHg. After a new Pilot wire (Abbott Vascular) was placed in the distal LCX, the ostial LCX was additionally dilated using a 2.5 × 15 mm Ryujin balloon to 14 atm. Although the blood flow in the distal LCX was slightly decreased due to dissection by the guide wire, the final result on coronary angiography was good (). Subsequently, both stents, including the distorted and elongated stent, were crushed to the LM wall (). Five days postoperatively, the patient was discharged in stable condition on triple antiplatelet agents including cilostazol. Six months later, she presented with chest pain and mild dyspnea, so coronary angiography was repeated, which showed no evidence of restenosis or progressive disease ().