N.K.C

41-year-old male patientHistory:Smoke 10 packs - year. Stent LAD, LCX 6 months ago caused ACS, CTO RCA.Clinical Presentation:Chest angina irregularly when exertion, CCS 3Vitals: BP 120/80 mmHg     HR: 78 bpm    Physical examination is normal 

- CBC: Hb 17.5 g/dl ( 13.5 -  17.5 g/dl ) ; PLT 240 G/L ( 150 - 400 G/L)- Biochemistry tests showed dyslipidemia : Creatinin: 100 micromol/l ( 74 - 110 micromol/l); Troponin I hs: 5.2 ng/l ( < 19.2 ng/l); GOT/GPT : 33/24 U/L; Cholesterol : 6.05 mmol/l (< 5.2mmol/l); LDL-C : 3.56 mmol/l (< 2.6 mmol/l); Triglyceride : 8.11 mmol/l ( < 1.7 mmol/l).- Echocardiographic parameters: Akinesis 2/3 interventricular septal, left anterior ventricular wall toward the apex. EF  50%  

- The proximal-middle LAD stent still has a good flow. 80-85% stenosis in the middle of LCX. There is a previous stent in the proximal of  LCX- Severe stenosis diffuses from proximal RCA, CTO from mid-RCA receives collateral circulation from LAD 

We use access:  Right radial artery; Introducer: 6F; Guiding catheter: EBU, 6F; Guidewire: Runthrough and Predilatation with 2.5x20 mmm balloon. However, we failed to deliver the stent into the mLCX through the previous stent in pLCX.We performed multiple balloon dilation using the buddy wire technique, using an additional guidewire SionWhen inserting the stent into the pLCX, we found entanglement and felt as if the stent of the pLAD was protruding into the ostial which also made it difficult to push the stent into the mLCX. The stent loss in the left main coronary artery. We used 1 more guidewire inserted to the side of the dropped stent, then twisted all 3 guidewires several times. The goal is to create a strong attachment of the guidewire to the dropped stent and to pull it gradually. We pulled the stent gradually toward the radial artery.We switched to right femoral artery access, Introducer 6F, guiding catheter EBU 3.75, 6 French, predilate with 3.0 x 15 mm balloonWe used Guidezilla to successfully insert DES 3.0 x 33 mm into the mLCX and performed post-dilatation several times with a 3.0 x15 mm NC balloonThe final result is good flow, TIMI 3

·   Stent loss is not an exceptional complication of percutaneous coronary intervention and can be life-threatening.·   Most management therapy brings good results, but there are cases in which urgent CABG is needed or causes ischemic complications or death.·   Careful lesions preparation and the use of supportive tools such as Guide Extension Catheter like Guidezilla, especially those that are calcified, tortuosity, or need to be passed through a previous stent, can help limit this complication.