Surgical Retrieval of Dislodged Stent During Transradial Coronary Intervention

ABSTRACT: Coronary stent dislodgement is a rare but serious complication during percutaneous coronary intervention. During transradial coronary intervention, retrieval of a dislodged and deformed stent into the guiding catheter is difficult or impossible, since a small 6 Fr guiding catheter and sheath system is commonly used. I describe a new method to retrieve a dislodged and damaged stent during transradial coronary intervention. When a dislodged and unexpanded stent is not pulled back completely into the guiding catheter, the damaged stent and guiding catheter can be withdrawn together into the radial artery and retrieved successfully by radial artery cutdown and repair method.

J INVASIVE CARDIOL 2012;24(8):E179-E181

Key words: stents, complications, percutaneous coronary intervention

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Stent dislodgement or migration is a rare but potentially serious complication of percutaneous coronary intervention (PCI). It can result in systemic or intracoronary stent embolization, which may lead to fatal consequences, including coronary thrombosis, emergency coronary artery bypass graft surgery, or even death.¹ Retrieval of a dislodged stent can be performed either percutaneously or surgically. Percutaneous stent retrieval can be successfully achieved using a number of techniques including small balloon technique, double wire technique, loop snare, or forcep.^2-7 However, retrieval of the disfigured stent via the arterial sheath could be impossible despite upsizing the femoral sheath to 11 Fr and result in vessel injury.⁸ When stent dislodgment occurs during transradial coronary intervention (TRI), retrieval of a dislodged and disfigured stent into the guiding catheter is difficult or impossible because 6 Fr guiding catheter and sheath system is commonly used.

Herein, I describe a novel surgical method used in 2 cases to retrieve a dislodged and damaged stent during TRI. After its retrieval from the coronary artery, the damaged stent sandwiched between the balloon and the guiding catheter tip and was then withdrawn into the radial artery and removed successfully by surgery under local anesthesia in the catheterization laboratory.

Case Report 1. A 73-year-old male patient was presented with unstable angina for one week. He was treated 2 years ago with 3 drug-eluding stents in proximal segment of the left anterior descending artery (LAD) and proximal and distal segments of the right coronary artery (RCA).

Diagnostic coronary angiography performed via the right radial artery revealed that 3 stents were patent but a new, tubular 90% stenosis was found in the middle segment of the RCA. After cannulation of the right coronary ostium with a 6 Fr AR-2 guiding catheter (Launcher, Medtronic) and crossing of the lesion with a 0.014-inch guidewire (Runthrough NS), a 2.5 mm x 20 mm balloon catheter (Ikazuchi) was used to predilate the lesion in the RCA with a reference vessel size of 3.0 mm. Stenting of the lesion was then attempted using a 3.0 mm x 24 mm stent (Endeavor Resolute, Medtronic). However, the stent could not be advanced across the proximal RCA because of previous stent. Even with another guidewire (Rinato) placed in the RCA, the stent failed to pass the proximal RCA. Then I tried to pull back the unexpanded stent into the guiding catheter but failed to enter completely. The guiding catheter and stent, which was partially entered and stuck in the guiding catheter, were carefully withdrawn together into the radial artery (Figure 1).

In the middle area of the forearm, force was given to pull the stent back into the guiding catheter but only the stent catheter was pulled out and the stent was left in the radial artery. After that, the stent was not grabbed using a forcep or snare through both radial sheath and antegrade brachial route because the stent was stuck in the distal small radial artery and there was no space for forcep or snare. I decided to retrieve the stent by surgery. Under local anesthesia in the catheterization laboratory, a vascular surgeon incised the skin around 2 cm long and cut down the radial artery, retrieving the deformed stent successfully and repairing the radial artery (Figure 2). Two days later, the original RCA lesion was treated with stent through the femoral artery. The patient was discharged 2 days later with an improvement of anginal symptom and no complication in the arm and hand. Right radial pulse was intact at 3-year follow-up.

Case Report 2. A 70-year-old female patient was presented with chest pain for 2 months. She had taken medications for hypertension and diabetes mellitus. Diagnostic coronary angiography performed via the right radial artery revealed that a diffuse, calcified, 95% stenosis was found at the proximal and middle segment of the LAD. After cannulation of the left main tract with a 6 Fr XB-3.0 SH guiding catheter (Vista Brite Tip, Cordis) and crossing of the lesion with a 0.014-inch guidewire (BMW universal, Abbott Vascular), a 2.5 mm x 20 mm balloon catheter (Ryujin, Terumo) was used to predilate the lesion in the LAD. The first stent (Promus Element, 2.75 mm x 28 mm, Boston Scientific) was implanted successfully in the middle LAD lesion. However, the second stent (Promus Element, 3.5 mm x 28 mm, Boston Scientific) could not be advanced across the angulated, calcified lesion in the proximal LAD and slipped away from the balloon catheter.

After that, we tried to pull back the unexpanded stent and balloon catheter into the guiding catheter but failed to enter completely. The guiding catheter and the all stent system, which was partially entered and stuck in the guiding catheter, were carefully withdrawn together into the distal radial artery. After removal of guiding catheter, we tried to withdraw the stent into the arterial sheath, but failed. Finally, while pulling back the stent after removal of the arterial sheath, the stent was stuck near the puncture site of the radial artery (Figure 3). Under local anesthesia in the catheterization laboratory, a vascular surgeon incised the skin, cut down the radial artery, retrieved the distorted stent successfully, and repaired the radial artery. Five days later, the proximal LAD lesion was treated successfully with stent through the right femoral artery and the repaired radial artery was patent in the antegrade angiogram (Figure 4). The patient was discharged 2 days later with an improvement of anginal symptom and no complication in the arm and hand (Figure 5).

Discussion. Coronary stent dislodgement is an uncommon occurrence in modern PCI and is often associated with significant morbidity.^1,2 Retrieval of a dislodged stent can be performed either surgically or percutaneously using a variety of retrieval techniques, including catheter balloon inflated distal to the undeployed stent, twirling 2 wires around stent, loop snare, or forcep.² Cases in this report describe for the first time a novel surgical method, radial artery cutdown and repair for successful retrieval of damaged and distorted stent during TRI.

In TRI, a 6 Fr arterial sheath and guiding catheters are commonly employed. For removal of an undeployed but undamaged stent during transradial stenting, Kiemeneij et al⁹ recommend retrieval of the over-the-wire stent using a snare inserted through the existing radial sheath after the balloon catheter is removed. However, this technique cannot be applicable when, like in my cases, the damaged, deformed, and thus bulky stent cannot be removed through the 6 Fr guiding catheter or sheath.

When a dislodged stent during TRI is withdrawn into the aorta successfully but cannot be retrieved into the guide catheter because of stent damage or deformity, one option is to use a forcep or snare inserted through an 8 Fr or larger femoral arterial sheath to retrieve the stent in the ascending aorta. However, this technique carries the risk of stent embolization to a cerebral artery or iliofemoral artery system, or the risk of retrieval failure of the disfigured stent via the larger femoral sheath and resulting injury of the large femoral artery.⁸ Another option is retrieving the stent via the radial artery percutaneously, including antegrade brachial sheath insertion,¹⁰ or surgically. A technique implanting the stent in the distal peripheral artery as suggested by Kiemeneij et al⁹ may be less desirable in the brachial or radial artery. Furthermore, it is not appropriate to deploy the stent in the brachial or radial artery, particularly when the stent is damaged and deformed. When a damaged and deformed stent is withdrawn successfully into the radial or brachial artery, the arterial cutdown and repair method is useful for successful stent retrieval during TRI. This method is relatively easy and causes less vessel injury compared to techniques for stent retrieval through the femoral artery.⁸

These cases suggest that a dislodged and damaged stent during TRI can be retrieved successfully by the radial artery cut down and repair method if the stent can be withdrawn into the radial artery when the damaged stent is not pulled back completely into the guiding catheter.

References

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From the Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, South Korea.
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author reports no conflicts of interest regarding the content herein.
Manuscript submitted March 9, 2012 and accepted April 9, 2012.
Address for correspondence: Kwang Soo Cha, MD, PhD, FACC, FESC, FSCAI, Department of Cardiology and Medical Research Institute, Pusan National University Hospital, 1-10 Ami-dong Seo-gu, Busan 602-739, South Korea. Email: cks@pusan.ac.kr