Mr. MNO

63 years old gentleman with underlying hypertension for 20 years. He had history of ward admission in April 2020 for hypertensive emergency with acute pulmonary edema in another tertiary hospital. He was subsequently discharged well but had intermittent angina and dyspnea upon exertion. Hence he was referred to us for further evaluation and management. In view of his symptoms and medical history, we have scheduled him for an elective coronary angiography.

12-lead electrocardiography (ECG) showed sinus rhythm with no ST segment changes. Chest X-ray showed borderline cardiomegaly. Echocardiography showed mildly reduced left ventricular function with ejection fraction (EF) 48 % with hypokinesia at mid and basal infero-septal, mid and basal inferolateral segments. Full blood count, renal profile and liver function test were normal.

Coronary angiography via right radial artery with 5F Optitorque diagnostic catheter showed single vessel disease. He had a co-dominant right coronary artery with moderate disease, minor irregularities in the left anterior descending (LAD) artery, and 80 to 90 % stenosis from the proximal to mid left circumflex artery (LCX), across obtuse marginal 1 (OM1) branch (Medina 1.1.0). 
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Left coronary artery was engaged with 6F EBU 3.5 via right radial artery. A Sion Blue was wired into LCX and another Sion Blue was wired into OM1. Proximal to mid LCX was predilated with non-compliant (NC) balloon 2.5 mm, then followed by NC balloon 3 mm. Attempted to deliver a drug eluting stent (DES) measuring 2.75 mm x 48 mm, but had difficulty to place the stent at the lesion site. Hence we decided to predilate the lesion site further. However, noted inability to withdraw the stent into the guiding catheter. Upon close inspection of the angiographic images, noted the stent balloon at the proximal end was slightly inflated, and the proximal end of the stent was crumbled and invaginated. Therefore, the EBU 3.5, the coronary wires, and the stent were withdrawn en bloc under fluoroscopy guidance. Unfortunately, the stent got dislodged from the stent balloon and was stuck in the radial artery, close to the vascular access. Biopsy forceps Radial Jaw 4 (Boston Scientific) 2 mm was inserted directly into the existing right radial artery sheath 6F and the dislodged stent was retrieved successfully. Angiography of the right radial artery was done and neither dissection nor perforation was observed. We then continued with the percutaneous coronary intervention and proximal to mid LCX was stented successfully without complication.
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Patient was admitted overnight for observation and was discharged well the next day. Patient remained well and asymptomatic during clinic follow up 1 month after the PCI and his right upper limb was functioning well. This case shows the feasibility and safety of using biopsy forceps to retrieve a dislodged stent especially when the stent is near to the vascular access site.