TCTAP & AP VALVES 2020 Virtual

CASE20191030_017

CORONARY - Complications
Leave No Man Behind: Dislodged Stent During CTO Intervention
Rhuban Sundran¹, Kumara Gurupparan Ganesan¹
National Heart Institute, Malaysia¹,

[Clinical Information] - Patient initials or identifier number: Mr S.A -Relevant clinical history and physical exam: 47 year old was referred to our center for staged PCI to CTO LAD. He was admitted to a district hospital for recurrent chest pain on exertion. He has a background of diabetes mellitus and hypertension. PCI to ramus intermediate had been carried out at their hospital prior to referral. -Relevant test results prior to catheterization: HbA1c 7.7%, LDL: 1.7mmol/LHDL: 0.8mmol/LCreatinine: 67micromol/LHb: 13.8g/dl ECG - Sinus rhythm. No ischaemic changes.No Q waves.Echocardiogram - Preserved LV systolic function,EF 50%. No significant valvular disease. Apical, apical anterior, mid anteriorand anterior hypokinesia - Relevant catheterization findings: Angiogram FindingsLMS - NormalLAD - Long CTO from proximal segment. Collaterals from LCx to mid segment and collaterals from RCA to distal segment. Ramus Intermediate - Severe Stenosis - 2.25x38mm stent deployed.LCx - NormalRCA - Small. Severe mid segment stenosis. Failed PCI attempt to CTO LAD Rao.Cau Pre PCI.avi Rao.Cra Pre PCI.avi LAO.RCA pre PCI.avi
[Interventional Management] - Procedural step: Staged PCI to CTO LAD - Decision made for antegrade approachLeft system engaged with EBU3.5 7Fr guiding catheter. Sion Blue crossed into D1 with CORSAIR microcathetersupport. Microcatheter swapped to SASUKE. Wire escalated to GAIA 2nd and successfully crossed CTO LAD. Predilated with 1.5x15mm@16atm Sprinter Legend. IVUS - Diffusely diseased.Vessel size at mid segment- 2.0mm. Predilation: 2.0x20mm@16atm Sprinter Legend but unable to pass down 2.0x30mm RESOLUTE ONYX stent. FurtherPredilation: 2.5x12mm@14atm NC Euphora at proximal segment to allow stent to pass. Balloon expanded well. While attempting to remove the stent to decide on the next course of action, stent was noted to have dislodged. A small part of the stent remained inside the guiding catheter and the remainder in the LAD. Dislodged stent retrieved with EN Snare 2-4mm. Decision made to use GuideLiner to aid subsequent stent delivery. Unable to advance GuideLiner therefore advanced with balloon trapping. Further Predilation: NSE 2.25x13mm @ 14atm. Balloon expanded well. Mid LAD stented with RESOLUTE ONYX 2.0x26mm@12atm GuideLiner removed, DEBSequent Please Neo 2.0x25mm applied @10atm for 1 minute to D1. Overlap stenting till proximal LAD with RESOLUTE ONYX 2.75x22mm @12atm. Proximal end of stent postdilated with 4.0x9mm NC. Non flow limiting dissection noted distally but decision made not to intervene given size and fragility of vessel. TIMI 3 flow. dislodged stent.avi ENSnare.avi Post PCI.avi - Case Summary: It is important to consider all options in trying to retrieve a dislodged stent. We decided to use a snare rather than other techniques because the LAD prior to stenting was small, diffusely diseased with multiple dissections. Advancing another wire with multiple dissections or pushing the stent more distally with a balloon may have caused more harm. We should also be wary that the same complications can also occur with a 2.0mm stent. Finally, using a guide extension catheter such as GuideLiner is an important technique to consider. Using balloon trapping to advance the extension catheter also promotes a less traumatic advancement.

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