MJ 10463387

An 82-year-old female on the background of severe central chest discomfort and hypotension during hemodialytic session at this admission. Her current medical conditions were ESRD on regular Hemodialysis 3 times per week, Type 2 DM, Hypertension, Hypercholesterolemia. After HD termination, her        blood pressure was 105/70 mmHg and Heart rate was regular around 105 bpm. Chest auscultation revealed minimal crepitation both lower lungs. Her heart sound did not show significant murmur. Bodyweight 48 kgs

CBC: Hematocrit 30%, platelet 165,000 cell/cu.mm. Blood coagulation: within normal rangeserum creatinine 6.5 mg/dl, Serum sodium 136 meq/L, Potassium 5.1 meq/LECG: Sinus Tachycardia 116 bpm. LVH by voltage. ST-segment depression within leads II, III, AVF, V4-V6Chest radiography: Cardiomegaly with minimal vascular congestion.Cardiac Troponin-T 576 ng/LEchocardiogram: LVEF 26% with severely global hypokinesis. Moderate LA and LV enlargement. Moderate functional Mitral& Tricuspid regurgitation.

The coronary angiogram was performed via Right Femoral Artery, using 5F JR3.5 and JL3.5 diagnostic catheters.LM: The vessel was free of stenosis.LAD: There was 70% tubular stenosis at proximal to mid segment with heavy calcified.LCX: There was chronic total occlusion at proximal segment.RCA: Dominant vessel with 99% tubular stenosis at proximal to mid segment. There was subtotal occlusion at proximal PL branch.         LVEDP 20 mmHg without gradient across Aortic valve.

1. A 7Fr. JR 4.0 guiding catheter engaged into right coronary ostium.2. A 0.014inch Sion coronary wire was advanced across lesion into distal PDA.3. A 2.00x15 mm. Mini Trek balloon was used to pre-dilate lesion @ 10-14 Atm.4. A 2.75x20 mm. NC Europa balloon was used to pre-dilate lesion again up to 14 Atm.5. A 2.75x44 mm. Sirolimus DES was unsuccessful to advanced cover lesions after several attempts.   Unfortunately, the stent balloon was dislodged from metallic part during withdrawal step. The metallic stent was partially retained within RCA.   The coronary was also accidentally loss from RCA.6. The micro snare was attempted to retrieve the metallic stent for several times. Unfortunately, the metallic stent was floating to left main coronary     artery and subsequently wandered with bloodstream.7. The fluoroscopic examination revealed that the metallic part was temporarily stuck in atheromatous plaque within descending aorta.8. We decided to proceed for PCI RCA. The guiding catheter was re-engaging and coronary wire was re-advanced into distal PDA.9. Two 2.75x23 mm. Everolimus DES was deployed from proximal to mid RCA. A 3.00x18 mm. Everolimus DES was deployed from ostium RCA overlapped   with previous two stent. The 2.75 mm. and 3.00 mm. NC balloons were used to post-dilate within stents, respectively.10. The final angiogram showed good angiographic result with TIMI flow grade 3 in RCA.11. The retained stent in descending aorta was successfully retrieved with One snare catheter.

The stent dislodgement is unusual complication occurred in PCI procedure. However, it will usually make catastrophic consequences to operator who confronted with this trouble situation. Therefore, snare catheter manipulation skill is one of the prerequisite training experiences for all new interventionists. Furthermore, in patient who has hemodynamically constant and stable dislodged stent position, the percutaneous coronary intervention procedure can be completed before subsequent retrieval of wandering metallic stent part.