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Axial Deformation During Coronary Stenting: An Extreme Case
ABSTRACT: We describe a case of longitudinal stent compression induced by withdrawal of a “buddy wire,” which we managed by crushing the retracted struts using another stent. To the best of our knowledge, this is one of the first reports of this complication induced by wire manipulation.
J INVASIVE CARDIOL 2012;24(6):E122-E123
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Case Report. An 81-year-old patient was referred for coronary angiography due to crescendo angina and anterior T-wave inversion on the ECG. Coronary angiography revealed proximal occlusion of a non-dominant right coronary artery, moderate ostial circumflex lesion, and diffusely calcified significant left anterior descendent (LAD) disease (Figure 1A). Fractional flow reserve on the ostial circumflex lesion was 0.83, so that percutaneous coronary intervention of LAD was planned. Percutaneous coronary intervention was initially complicated by a wire-induced dissection distal to the third septal branch (Figure 1A, arrow). Multiple pre-dilations with 1.5 and 2.0 balloons were followed by successful deployment of a 2.25 mm x 20 mm drug-eluting stent (Promus Element, Boston Scientific) to mid LAD, which was extended proximally with a similar 2.5 mm x 28 mm stent. Both stents were then successfully post-dilated with a 2.5 non-compliant balloon. As the distal dissection was not completely covered (Figure 1B), we intended to implant a further stent distally. An attempt to pass a BMW Universal (Abbott Vascular) as a “buddy” wire was unsuccessful and the wire was withdrawn with a gentle sensation of some traction. Thereafter, a change in the appearance of distal stent was obvious, with marked axial shortening and the concomitant reappearance of distal vessel dissection (Figure 1C). Attempts to advance 2.0, 1.5, and 1.1 balloons and a Corsair catheter (Asahi Intecc) over the original wire failed. A new wire had to be passed laterally through the deformed stent struts allowing fenestration with 1.1 and 2.0 balloons. The retracted portion of the stent was then finally “crushed” with 2.25 mm x 20 mm drug-eluting stent with a good angiographic result (Figure 1D).
Discussion. Axial stent deformation or longitudinal compression has been very recently described as the mechanical consequence of either guide catheter or IVUS imaging.1,2 Recognition of the potential for this complication is important and it requires the operator to be particularly careful to ensure axial alignment prior to passage of balloons/devices through recently deployed stents. In the present case it is likely that distal stent struts were disrupted during placement of a buddy wire. The situation was probably aggravated by the presence of a distal dissection with possible vessel wall hematoma, which re-expanded once the distal struts were crushed and deformed. As the stent lumen was completely obstructed, rewiring was only possible between stent struts with crushing of the distal retracted portion of the stent. This achieved a reasonable result, although full stent coverage of the dissection was not possible.
References
- Pitney M, Pitney K, Jepson N, et al. Major stent deformation/pseudofracture of 7 Crown Endeavor/Micro Driver stent platform: incidence and causative factors. EuroIntervention. 2011;7(2):256-262.
- Hanratty CG, Walsh SJ. Longitudinal compression: a "new" complication with modern coronary stent platforms - time to think beyond deliverability? EuroIntervention. 2011;7(7):872-877. (Epub ahead of print).
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From Oxford University Hospitals, Oxford, United Kingdom.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Prof Banning has reported unrestricted research sponsorship from Boston Scientific Corp, no other author reports any disclosures, financial or otherwise, regarding the content herein.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 14, 2011, provisional acceptance given December 28, 2011, final version accepted January 2, 2012.
Address for correspondence: Prof. Adrian P. Banning, Oxford University Hospitals, Headley Way, Oxford OX3 9DU, United Kingdom. Email: Adrian.Banning@orh.nhs.uk
