SHA24/089006

Coronary Stent Dislodgment Abdulrahman Almoghairi Interventional Cardiology, Director of Invasive Cardiology, Deputy Director of Research Department, Prince Sultan Cardiac Center (PSCC), Riyadh

Case Presentation • 80 year old lady • With h/o Bronchial Asthma • Referred PSCC from peripheral hospital after she presented with ACS (NSTEMI) for the first time in her life • Upon arrival she is in mild chest pain at rest • O/E; thin lady, Wt was 47 Kg, normal CVS exam, not in failure, no carotid bruits.

• ECG: SR, T wave inversion in V1-6, I and aVL • ECHO; normal LV size , EF 35-40%, GIDD, akinetic mid anterior, anteroseptum, dyskinetic apex, mild MR, moderate TR • BUN 8 mmol/l, Creatinine 57 mmol/l, Hb 13 g/l • Coronary angiography; shown

RCA

LCA

Stent Retrieval

Final Angiography

Loss of control or loss of communication

• Dislodgement of a stent from the delivery system is uncommon • Embolization or Thrombotic events • Morbidity and mortality

Incidence of stent loss • Manually crimped stents : 1.43 – 8.3% • Factory- mounted stents: 0.38% • The frequency of stent loss has decreased from 1.04% to 0.27% since the use of factorypremounted stents Eggebrecht H. et al.. Catheter Cardiovasc Interv 2000; 51: 432-40

reference

Publication year

Incidence of stent loss

Foster-Smith

1993

3/193 (1.6%)

Alfonso

1996

17/495 (3.4%)

Elsner

1996

6/419 (1.43%)

Cantor

1998

108/1303 (8.3%)

Eggebrecht

2000

20/2211 (0.9%)

Brilakis

2005

38/11773 (0.32 %)

Risk Factors • • • • • • • •

Tortious, calcified anatomy Previous CABG Coronary dissection Partially deployed stent Poor guide catheter support Direct stenting of heavily calcified lesion Bifurcation strategies Lesion located on a bend

Catheterization and Cardiovascular Interventions 65:333–340 (2005)

Retrieval methods

Single-balloon technique

Brilakis ES and Garratt KN. Device loss during percutaneous coronary intervention: Incidence, complication, and retrieval methods. In: Stephen G. Ellis, MD., David R. Holmes, Jr., MD. Strategic approaches in coronary intervention. Philadelphia: Lippincott Williams and Wilkins Inc; 2006. P434-44.

Double balloon technique

Oxford Textbook of interventional cardiology, Simon Redwood,2010, P534

Double wire, Twisted guidewires technique

Rotate clockwise about 15–20 times

Strategic approaches in coronary intervention

By Stephen Geoffrey Ellis, David R. Holmes

Fig. 2. AlgorithmCatheterization for management of stent embolization. and Cardiovascular Interventions 65:333–340 (2005)

• Despite these methods, the stent retrieval is unsuccessful in at least 30% of cases • Deployment at an unintended site or crushing against vessel wall

Avoid