A  74 Chinese Female with Dyslipidemia and Hypertension with chest discomfort for 2 days presented to our emergency department. On arrival her pressure was 122/72, pulse was 68. Clinical examination showed no pedal edema and heart sounds were unremarkable.ECG showed RBBB, T inversion V1- V5, ST depression II, III, avF. Bedside ECHO was 56 %. Her HAS-BLED score was 2. She previously underwent a CT angiogram at a private centre which showed severe stenosis of 80% over the LAD.

Her Blood workup revealed Hemoglobin of 12.2g/dl, white cell count of 4.4, and platelet count of 210. Her Liver function test was unremarkable. Her Urea was 6.1, and creatinine was 78. Her lipid profile revealed total cholesterol of 4.5, with LDL of 2.6, HDL of 1.58, and TG of 0.65. Her HBA1c was 6.5%. Troponin I was 13. ProBNP was less than 60.

An angiogram revealed that the Left main was smoothLAD --proximal to mid-60 %, LCX showing mid-diffuse disease - 80-90%. RCA was smooth. Our strategy was PCI to LCx and RFR to LAD, and if physiologically significant, PCI to LAD as well.

LMS engaged with EBU 3.0 6FR- LCX with Sion Blue and Runthrough Floppy to LAD. After successful DCB SeQuent Please 2.75mm x 30 to MLCx, RFR to LAD showed 0.81-significant lesion.    Predilated LAD with 2.75x20mm Scoreflex up to 18atm. However, there was a Type B dissection, so decided to stent mLAD withCRUZ 3.5x48mm. Both wires were entangled, and after entanglement, the CRUZ inadvertentlypassed to LCX instead of LAD. While pulling back the stent, the stent stuck in LM-Ostium of LCx    We suspected the stent was crumpled at Proximal edge, exposing the balloon 5mm.    Decided on a Right Femoral access 6FR with JR4 7FR.Our first step was Small balloon technique, attempted a 1.5x20 balloon, however, the balloon wasunable to cross.The next strategy was the Snare technique, in which the stent was managed to be retracted with aGuiding Catheter en bloc into the aortic arch to the descending aorta.    Subsequently, Goose snare technique using RFA, successfully pulled stent partially into JR4, then via balloon trapping 2.5x 15mm, pulled 1/3 of the stent inside    Using Multisnare 15-21, managed to pull down to Iliac Artery, pulled stent-JR4 en-bloc    Unfortunately, stent dislodged at the Right Femoral Sheath, and balloon above that     Managed to snare it successfully, then pulled out the Right Femoral Sheath, existing guidewire, and stent at the distal sheath     Femoral shot was taken using EBU, no leak or evidence of Dissection    Stage PCI to LAD was done on Day 3 and was discharged on D5 of admission.    

Stent dislodgement is a rare but serious complication. Transradial is preferred but limitations include the small size of the radial artery and the risk of spasm restricting the ability to upsize in sheath size. The transradial approach may be suitable for non-critical coronary segments where the stent is crushed against the coronary vessel wall. For  LMS or bifurcation lesions, transfemoral may be more suited. Failure to retrieve the dislodged stent can result in several complications,including stent thrombosis, myocardial infarction, embolic stroke, and death. Although there are a few techniques available, operators should customise the best-suited method to minimise the risk of complications