Successful Transcatheter Retrieval of an Embolized Stent from the Left Ventricle

Dislodgement and embolization of coronary stents before deployment are rare and challenging complications of intracoronary stenting. Reported incidence varies between 0.56–0.90%.1,2 Intracoronary embolization may cause arterial occlusion with potentially adverse sequelae and may result in clinically relevant cardiac ischemia or peripheral embolization during rescue attempts. However, systemic embolization complicating intracoronary stenting before deployment is rare and was not associated with any clinical sequelae. Different methods for nonsurgical stent retrieval have been suggested; they include the use of a distally placed balloon,1,3,4 a second wire,5 forceps,3,6 retrieval snares1,7 and baskets.8 We report a previously undescribed case of successful retrieval of an embolized stent to the left ventricle. Case Report.A 60-year-old woman was referred to our hospital due to chest pain on exertion. She had been diagnosed with hypertension 5 years ago. Coronary angiography disclosed an 80% eccentric stenosis of the proximal left anterior descending coronary (LAD) artery and an 80% stenosis of the left circumflex (LCX) artery. Two senior cardiologists decided to perform coronary intervention for the LAD and CX stenoses. After placing a 7 French sheath in the right femoral artery, a Q4 guiding catheter (Cyber Schmed Life Systems) was engaged to the left main coronary artery ostium. After engagement, a 0.014´´ Shinobi guidewire (Cordis Corporation, Miami, Florida) was advanced to the distal part of the LAD. Because of vessel tortuosity and lesion calcification, it was decided to first perform predilatation. Therefore, a 2.5 x 20 mm Bonnie coronary dilatation catheter (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was advanced over the guidewire to cross the lesion. Inflation up to 11 atmospheres (atm) resulted in a type C dissection. Because of the dissection and ongoing chest pain, we decided upon stent implantation. For this purpose, a 2.5 x 18 mm stent (Medtronic AVE, Santa Rosa, California) was advanced to the lesion, but it was unable to cross the target lesion (Figure 1). We attempted to take the stent back through the guiding catheter and the delivery system was pulled back a little bit. During retraction, it was displaced from its delivery balloon. Because of the “whip effect” of the guiding catheter and guidewire, the entire system moved into the left ventricle (Figure 2). The stent was free around the guidewire. Therefore, the original balloon was withdrawn and a 2.0 x 20 mm, low-profile Adante balloon (Boston Scientific/Scimed, Inc.) was advanced over the guidewire distal to the stent. Before advancing the balloon, a Gooseneck snare (Microvena Corporation, White Bear Lake, Minnesota) was used to stabilize the stent within the ventricle (Figure 2) and the balloon was then inflated inside at 2 atm. Because of increased stent diameter after balloon inflation, it was still not possible to retrieve through the guiding catheter. Therefore, the guiding catheter and the balloon with the inflated stent were taken out of the ventricle back up to the iliac artery. Stent retrieval trough the vascular sheath was impossible; during our attempt, it was entrapped within subcutaneous tissue (Figure 3). Afterward, we did not make an attempt because of the potential risk of inguinal complications. Because of dissection of the target lesion, the patient began to suffer from squeezing chest pain with concomitant ST-segment elevation. Therefore, we referred the patient to urgent coronary artery bypass surgery. Discussion. Dislodgement and embolization of coronary stents before deployment are rare and challenging complications of intracoronary stenting. Reported incidence varies between 0.56–0.90%.1,2 Intracoronary embolization may cause arterial occlusion with potentially adverse sequelae and may result in clinically relevant cardiac ischemia or peripheral embolization during rescue attempts. However, systemic embolization complicating intracoronary stenting before deployment is rare and was not associated with any clinical sequelae. Stent dislodgement tends to occur when negotiating a tortuous, calcific artery with a hand-mounted stent, especially if the artery is irregularly calcified or when applying a rigid stent. Inadequate guiding catheter support or positioning has additional risk. A previously placed stent, dissection and inadequate dilatation increase the risk of stent dislodgement. In addition to procedural and coronary risk factors, hand-mounted stents and coil stents have a greater tendency to dislodge than the others because they adhere less well to the balloon surface. Stent visibility is also important in delivery and retrieval procedures.2 Percutaneous removal of dislodged and embolized stents is an appealing method for replacing more invasive operative interventions with cardiopulmonary bypass, which may be more hazardous in these often severely ill patients. These methods have been explained; they include the use of a distally placed balloon,1,3,4 a second wire,5 forceps,3,6 retrieval snares1,7 and baskets.8 When transcatheter techniques fail during retrieval, surgical approaches are needed.9 Recently, it has been reported that the guardwire, which is used for the prevention of distal embolization of atheromatous or thrombotic particles, can be used for successful retrieval procedures.8 This report describes a patient who underwent stent implantation to the LAD, during which the stent and delivery system moved into the left ventricle. The stent was removed non-surgically with an angioplasty balloon and a snare without any complications. Stent dislodgement and embolization are infrequent complications of intracoronary stenting. Non-surgical removal is readily performed with a low-profile balloon.

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