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TCTAP C-104

To Knot or Not to Knot

By Dhiman Banik, Smita Kanungo

Presenter

Smita Kanungo

Authors

Dhiman Banik1, Smita Kanungo1

Affiliation

National Heart Foundation Hospital & Research Institute, Bangladesh1,
View Study Report
TCTAP C-104
Coronary - Complication Management

To Knot or Not to Knot

Dhiman Banik1, Smita Kanungo1

National Heart Foundation Hospital & Research Institute, Bangladesh1,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

¡Ú60 years Lady.
¡ÚChronic Coronary Syndrome-III (Having exertional chest pain despite optimum medical management).
¡ÚRisk Factor – HTN.

¡ÚPhysical examination:-
General Examination-
Pulse: 74 bpm, BP-130/90 mm-Hg with no other significant abnormality.
Systemic Examination: Unremarkable.


Relevant Test Results Prior to Catheterization

¡ÚNormal blood biochemical parameters.
¡ÚECG- T inversion in leads II, III & aVF.
¡ÚECHO: Regional Wall Motion Abnormality (RWMA) with LVEF-40%.



Relevant Catheterization Findings


Interventional Management

Procedural Step

¡ÚFirst, after engaging with the guide catheter, RCA was wired with a run through floppy wire and the lesion was pre-dilated with a 2.0x12mm NC Balloon catheter.
¡ÚThen a 3.0x38mm DES was taken to be deployed, but during the stent delivery, the catheter was displaced as RCA was anomalous in origin. Moreover, during catheter manipulation the floppy wire also came out from the RCA and the stent was dislodged from the delivery system, floating in between the proximal RCA and the Aorta.
¡ÚAfter that, stent retrieval strategy was taken. RCA was cannulated once again and wiring was done with a floppy wire which was placed distally.
¡ÚAt first, stent retrieval was attempted with a snare but did not work out as it was small in size.
¡ÚThen the next strategy was twirling of wires- two other wires were taken and both the wires were twirled around the dislodged stent. We were trying to make a knot with the double wires over the proximal part of the dislodged stent but unfortunately failed to hold stent.
¡ÚThen we  proceeded with a homemade snare approach. In this method, a large loop was made with floppy wire while keeping a small sized balloon partially inflated at the distal part of the catheter. At this point we succeeded to hold  the dislodged stent and brought it back along with the guide catheter.
¡ÚThen a new 3.0x 38mm DES was deployed in the RCA with furthermore pre-dilatation and post dilatation.
¡ÚA 2.5x40 mm DES was also deployed in LCX and TIMI III flow established.


Case Summary

Stent dislodgement can be effectively managed by percutaneous stent retrieval methods. Besides the conventional methods, sometimes innovative measures are needed to be taken, like we succeeded with the help of a homemade snare loop. However, every catheterization laboratory needs to be equipped with instruments for any complexity and familiarizing with these retrieval methods and techniques could be crucial for the interventional cardiologists.