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