A 69-year old female with hypertension and dyslipidemia

She presented with very high-risk NSTEMI and cardiogenic shock on IABP. The CAG showed TVD with severe stenosis of LM bifurcation. She was referred to our hospital for coronary bypass surgery. Unfortunately, the operation had to be postponed due to her having acute large left MCA infarction and lobar pneumonia. The heart team planned to proceed with urgent PCI after pneumonia improved. Furthermore, she developed refractory ventricular tachycardia; VA-ECMO was attempted for maintained hemodynamics. 

EKG showed sinus rhythm with aVR elevation and diffuse ST depression at V2-V6, I, aVL. Troponin T was 516 ng/L. Transthoracic echocardiogram showed severely impaired left ventricular systolic function (LVEF 30%) with severe hypokinesia at anterior and anterolateral wall.

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The coronary angiogram demonstrated severe stenosis of ostial left circumflex and left anterior descending arteries (LM bifurcation, Medina 0,1,1). The proximal to mid LAD had heavy calcification with moderate stenosis. The right coronary artery had chronic total occlusion that received collateral flow from left coronary system.
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The T-stenting technique via the femoral approach was used. After deployed the drug eluting stent (DES) at ostial LCx with DES 3.0 mm x 13 mm, mid LAD with DES 2.5 x 32 mm and ostial LAD with DES 3.0 x 19 mm, the coronary angiogram demonstrated moderate stenosis at the body and distal LM. As a result, the DES 4.5 x 8 mm had to be placed at the LM. Following the deployment of LM stent and post-dilated with non-compliance 5.0 mm balloon, the LM stent disappeared and was not seen along the guiding and femoral sheath. The intravascular ultrasound (IVUS) was prompted into the LAD, showing dislodgement of the partially deployed LM stent in the proximal LAD. We then optimally deployed the dislodged stent using the non-compliance balloon 3.0 x 15 mm at the proximal LAD effectively. The final IVUS showed optimal stent apposition and good expansion without stent edge dissection and we deferred to stent the LM due to the minimal luminal area of LM was 14 mm². Her hemodynamic was improved and VA-ECMO was successfully weaned off 48 hours after procedure. The echocardiogram demonstrated improved left ventricular contraction (LVEF 50%) with mild hypokinesia at anterolateral wall. She gradually recovered and could be further discharged from the hospital.
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Dislodgement of the coronary stent during percutaneous coronary intervention is a serious complication. This report demonstrated the successful management of total stent loss with guide wire in situ by the recrossing technique. The IVUS is particularly helpful in the determining the characteristics within LM lesion, and its use following LM intervention improves clinical outcomes.