Nonsurgical retrieval of embolized coronary stents

Two stents' dislodgement in the left main coronary artery: a case report

BACKGROUND

Stent dislodgement is a life-threatening complication that can result in coronary artery embolization, stent thrombosis, acute myocardial infarction, and even death. Severely angulated, heavily calcified, and previously stented coronary arteries are associated risk factors. With the development of different lesion preparation techniques and the drug eluting stent era, the reported incidence of stent dislodgement has decreased to < 1% in the last few years.

CASE PRESENTATION

We report a case of a 64-year-old Moroccan man complicated during percutaneous intervention in the left main artery by the loss of two stents. This complication was successfully managed by passing the stent's balloon into the stent and then fully expanding it. In our case, the device's characteristics were involved and could play a role in such complications, but it is still not well understood.

CONCLUSIONS

The main treatment option is stent retrieval with different available techniques. If retrieval of the stent is impossible, crushing it against the blood vessel wall could be considered.

Migrated coronary stent into the left internal carotid artery: a rescue technique

Coronary stent dislodgement and migration is a rare phenomenon that can potentially result in life-threatening complications. We encountered the unusual case of a coronary artery stent that stripped from its delivery balloon and embolised into the left internal carotid artery during percutaneous coronary intervention. Such an event is a stressful experience for the interventional cardiologist but also an uncommonly encountered situation for a neurointerventionalist whose expertise may be sought to help navigate the situation. Planning the interventional approach and taking into consideration the tools available as well as potential complications is crucial to maximise the chances of best possible outcome for the patient. We were able to retrieve the stent safely and successfully, but, at the same time, we were prepared to manage any adverse events in the best way possible.

Diagnosis of Coronary Stent Dislodgement With Transthoracic Echocardiogram: A Case Report

Coronary stent dislodgment is a rare complication of percutaneous coronary intervention (PCI). Although stent dislodgment typically occurs immediately in the intraoperative or perioperative period, it can infrequently occur subacutely in the post-operative period. Diagnosis of stent dislodgment can be seen with various cardiac imaging modalities, from transthoracic and transesophageal echocardiogram to cardiac computed tomography or magnetic resonance imaging to direct visualization on fluoroscopy during cardiac catheterization. Given the rarity of this entity, there is a lack of established common practice, gold standard for treatment, and/or procedural data. Instances are managed on a case-by-case basis, using the imaging modalities readily available at the institution and treatment modalities the interventionalist or surgeon is most comfortable with. Therefore, management of stent dislodgment consists of conservative, percutaneous, or surgical interventions on a case-by-case basis. We present a case of right coronary artery stent migration that was incidentally diagnosed with routine transthoracic echocardiogram.

A Challenging Case of Stent Dislodgement During Percutaneous Coronary Intervention Complicated by Peripheral Embolization

We report a challenging case of stent dislodgement for a 49-year-old male with a history of end-stage renal disease and insulin-dependent diabetes undergoing an elective coronary angiogram for cardiac risk stratification before kidney transplant surgery. A diagnostic transradial coronary angiogram was performed showing two severe type A lesions to the proximal and distal left circumflex artery (LCx). While attempting to stent the proximal LCx, the stent dislodged to the left main coronary artery (LMCA). The stent was successfully retrieved from the LMCA via the transradial route using the small balloon anchoring technique. Unfortunately, while attempting to retrieve the stent-balloon assembly, the stent was accidentally stripped off the balloon embolizing to the right superior gluteal artery. Given the stable location, no attempt was made to retrieve the stent and the patient had no complications on follow-up. This case highlights the challenges in managing coronary stent loss including risk factors for stent dislodgement, methods to retrieve the stent, and the risk of stent embolization.

ECG-Gated CCTA in the Assessment of Post-Procedural Complications

INTRODUCTION

The aim of our study was to assess the role of ECG-gated coronary CT angiography (CCTA) in the diagnosis, imaging follow-up, and treatment guidance in post-procedural/surgical interventions in the heart and thoracic aorta (PTCA, TAVI, PMK/ICD placement, CABGs).

MATERIALS AND METHODS

We retrospectively evaluated 294 ECG-gated CCTA studies performed in our center from January 2020 to January 2023. CCTA studies were acquired to detect/exclude possible complications related to the endovascular or surgical procedure.

RESULTS

There were 27 cases (9.2%) of post-procedural complications. Patients enrolled in the study were 18 males and 9 females (male/female ratio: 2), with age ranging from 47 to 86 years (mean age, 68.3 years). Among percutaneous coronary intervention (PCI) complications, coronary intimal dissection with ascending aorta involvement was found to be the most frequent complication after PTCA (22.2%). Vascular wall pseudoaneurysm formation (11.1%) and coronary stent misalignment or displacement (14.8%) were complications less frequently encountered after PTCA. Right atrial or ventricular perforation with associated hemopericardium were the most common complications (18.5%) after pacemaker implantation. Complications encountered after aortic valve interventions were loosening and dislocation of the prosthesis associated with aortic root pseudoaneurysm (7.4%), para-valvular leak (11.1%), and hemopericardium (7.4%). In one patient who underwent transcatheter repair of patent foramen ovale (3.7%), CTTA detected the dislocation of the Amplatzer septal occluder.

CONCLUSIONS

ECG-gated CCTA is a fundamental diagnostic tool for the detection of post-procedural endovascular/surgical complications to enable optimal patient management. Radiologists must be familiar with the use of cardiac synchronization in the course of CT and must be aware of all possible complications that can occur in the context of acute settings or routine follow-up studies.

Investigation of the small-balloon technique as a method for retrieving dislodged stents

The small-balloon technique used to retrieve a dislodged coronary stent is less studied. We investigated the small-balloon technique to study the capture force and retrieval rate of dislodged proximal or distal stents. We developed a retrieval model for stent dislodgement and performed bench tests to compare proximal and distal capture. We evaluated capture force by capture site in a fixed stent dislodgement model and capture force and retrieval rate by capture site using a retrieval model of stent dislodgement. Three-dimensional (3D)-micro-computed tomography (CT) was used to scan the captured conditions of the distal (DC) and proximal (PC) groups. Stent, balloon shaft, and guiding catheter (GC) diameters were measured. Retrieval areas within GC were calculated and compared. The force was significantly lower in the PC group than in the DC group (p < 0.01). Successful retrieval was achieved in 100% and 84.8% in the PC and DC groups, respectively. The force required to retrieve the dislodged stent was significantly lower in the PC group than that in the DC group (p < 0.01). The force was significantly lower in the successful cases in the DC group than in the unsuccessful cases (p < 0.01). The retrievable areas in the PC and DC groups were 67.5% and 32.7%, respectively, as calculated from the values measured from the 3D-CT images. The success rate of PC was higher than that of DC using the small-balloon technique. The smaller proximal stent gap in the PC method facilitated the retrieval of the dislodgement stent.

Balloon-mounting stent for intracranial arterial stenosis: A comprehensive and comparative systematic review and meta-analysis

INTRODUCTION

As one of the major causes of acute ischemic stroke, intracranial arterial stenosis necessitates an intervention that ranges from medical treatment to balloon angioplasty and stenting. Self-expandable stents (SES) and balloon-mounted stents (BMS) are two types of stents and their comparative efficacy and safety for intracranial stenosis are not well established.

METHODS

Studies that investigate balloon-mounted stenting for intracranial stenosis were extracted from PubMed, Scopus, and Cochrane library. We sought to gather data on the success rate, change in mean arterial stenosis, and complications such as minor and major stroke and death (MMD), symptomatic intracranial hemorrhage, myocardial infarction, all-cause mortality, and in-stent re-stenosis.

RESULTS

3049 patients from 35 studies were included in this study. 20 studies investigated BMS alone and others compared BMS with SES. BMS was significantly more effective in reducing the degree of stenosis compared to SES (Difference in mean -5.953, CI 95% -7.727 to -4.179), had less complications compared to SES such as MMD (8.5% vs. 11.2%) and less in-stent re-stenosis (18.6% vs. 19.6%), but patients with SES experienced a lower rate of all-cause mortality(1.7% vs. 4.1%).

CONCLUSION

Intracranial stenting with BMS is more effective in reducing the degree of stenosis and has lower rates of complications when compared to SES.

Innovative Guide Extension Catheter Trapping Technique to Retrieve a Lost Stent From a Coronary Artery

A stent that was being implanted in the left circumflex artery, to treat an iatrogenic dissection, became dislodged at the ostial left circumflex artery on a previously deployed stent implanted for the treatment of a distal left main bifurcation stenosis. We describe here a novel technique to retrieve the device safely. (Level of Difficulty: Advanced.)

Case Report: Optical Coherence Tomography Usage for Treatment of the Chronically Lost Stent in the Left Main Coronary Artery

Acute adverse outcomes of a stent loss during percutaneous coronary intervention (PCI) are well described, however, data on long-term consequences are scarce, especially with intravascular imaging. We report a case of a coronary stent loss in the left main and ostial left circumflex artery (LCx) bifurcation and its migration into the LCx ostium during PCI procedures. This rare complication, which was not immediately noticed, was verified and successfully resolved 5 months after using optical coherence tomography and right trans-radial access. Considering the infrequency of this complication, few cases have been reported, however, our case has several distinct specificities. We aim to encourage the crushing technique in cases of chronic stent loss when the retrieval is not an option and highlight the optical coherence tomography (OCT) value in imaging and evaluation of similar complex settings.

Complications of stent loss during treatment of a heavily calcified and tortuous chronic total occlusion

Stent loss can occur during percutaneous coronary interventions (PCIs) and can lead to complications such as coronary occlusion, perforation or dissection. Stent retrieval is often attempted but may lead to additional complications. We describe a case of stent loss during chronic total occlusion PCI. The small balloon technique failed to retrieve the stent. The stent was snared but could still not be removed. Retrieval attempts were complicated by large vessel perforation. A covered stent was deployed covering the lost stent and successfully sealing the perforation.

What's That in the Aorta? A Case of Asymptomatic Dislodged Ostial Right Coronary Artery Stent That Was Noted as an Echodense Material in the Aortic Valve on Transesophageal Echocardiogram

A 58-year-old female with a history of coronary artery disease (CAD) with remote percutaneous intervention (PCI) to ostial right coronary artery (RCA) with a bare-metal stent represented with unstable angina. Left heart catheterization (LHC) showed 90% stenosis of the previously stented ostial RCA with a moderate disease in the circumflex and left anterior descending arteries (LAD). LHC had also demonstrated that the previously placed ostial RCA stent, 19 years ago, was dislodged with only 3-4 mm within RCA and the remainder 10-12 mm in the ascending aorta. The patient miraculously had remained largely asymptomatic of this dislodged RCA stent for many years. Subsequent transthoracic echo (TTE) showed moderate-severe mitral regurgitation (MR). Therefore, she was worked up for a possible single-vessel coronary artery bypass graft surgery (CABG) with mitral valve replacement/repair. However, on transesophageal echo (TEE), MR was noted to be moderate in severity. Also, an echodense material was noted on the right coronary cusp (RCC) of the aortic valve, which was deemed to be the dislodged RCA stent. As the MR was moderate, the patient underwent successful complex PCI of ostial RCA.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Successful percutaneous retrieval of a detached microcatheter tip using the guide-extension catheter trapping technique: A case report

A 55-year-old male with stable angina pectoris was referred to our hospital. Coronary angiography showed severe stenosis from the proximal to the middle part of the left circumflex artery (LCX). Based on the severity of lesion calcification, we performed percutaneous coronary intervention with rotational atherectomy. After crossing a 0.014-inch guidewire, we replaced it with a rotawire using a microcatheter. Following the retrieval of the microcatheter, we noted that a radiopaque tip of the microcatheter had been detached at the site of severe stenosis in the proximal part of the LCX. We advanced a guide-extension catheter to this site and wedged the detached tip using a balloon catheter (2.0-mm diameter; 12-mm length) in the guide-extension catheter. The detached tip was successfully retrieved along with the guide-extension catheter. After passing two guidewires into the main vessel and the side branch, we dilated the lesion using a 2.5-mm non-compliant balloon. Finally, we implanted two sirolimus-eluting stents, followed by post-dilatation with a 3.75-mm non-compliant balloon. This approach resulted in excellent dilatation and blood flow. Use of the guide-extension catheter trapping technique (i.e. use of a guide-extension catheter and a small balloon catheter) resulted in the successful percutaneous retrieval of a detached microcatheter tip. <Learning objective: We occasionally encounter adverse events related to the detachment or breakage of devices when performing percutaneous coronary intervention. The guide-extension catheter trapping technique using a guide-extension catheter and a small balloon is a useful approach for the retrieval of dislodged or entrapped devices.>.

Right Coronary Artery Stent Dislodgment during Primary Percutaneous Coronary Intervention. To Leave or to Retrieve?

Coronary stent dislodgment and embolization are rare and challenging complications of percutaneous coronary intervention that may result in serious and fatal complications attributed to the loss of blood flow of the coronary, cerebral, or peripheral circulations. Percutaneous management is successful in most cases using different techniques and devices, but surgery may be required. We report two cases of stent dislodgment during primary PCI for the right coronary artery with different management approaches and outcomes.

Coronary artery bypass as a treatment of stent dislodgement: A case report

Introduction

Stent dislodgement is a known complication during coronary angiography. Different methods are used to retrieve it including open heart surgery.

Case presentation

A 71 year-old male with stable angina was scheduled for elective coronary angiography. Angiography showed two significant stenosis: one in the proximal right coronary artery (RCA) and one in the left anterior descending artery (LAD). Upon deployment of the right coronary stent, it got lodged and the cardiologist was unable to retrieve it. The patient started to experience angina and his ECG showed ST segment elevation in the inferior leads. Emergency CABG was performed.

Conclusion

Stent dislodgement is a rare but serious complication. Most cases are treated by interventional methods; however, CABG is still needed in some cases.

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Stent dislodgement is not a common complication of coronary angiogram.

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Dislodged stents are usually removed by catheterization.

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Coronary artery bypass surgery CABG is needed if retrieval is not successful.

Acute Stent Loss and Its Retrieval of a Long, Tapering Morph Stent in a Tortuous, Calcified Lesion

A 72-year-old male with diabetes and smoking as coronary risk factors was evaluated for chronic stable angina - Canadian Cardiovascular Society III - despite guideline directed medical treatment which revealed a diffuse, tortuous, calcified narrowing (90% stenosis) in left circumflex (LCx) coronary artery. After predilatation, a 3.0 - 2.5 × 60 mm BioMime Morph stent - long tapering stent (Sirolimus eluting stent, Meril life Sciences, India) - was tracked which failed and dislodged to right deep femoral artery during its pullback. It was successfully retrieved by EN snare: 6 - 10 mm (Merit Medical, USA) by contralateral femoral approach. Lesion was further dilated and successfully stented with another 3.0 - 2.5 × 60 mm BioMime Morph stent at 10 atm pressure showing proper stents expansion with TIMI-3 coronary flow. Our case highlights trackibility issues and importance of adequate lesion preparation before stent deployment in a tortuous and calcified vessel especially with very long stent. To the best of our knowledge, this is the first such case report demonstrating dislodgement and successful retrieval of long, tapered Morph stent.

Endovascular Stents: Market Vigilance and Risk Factors

With the aim of enhancing the safety and reliability level of coronary stents, we analyzed data collected from accident reports drawn from the MAUDE database (Manufacturer and User Facility Device Experience Database) of the FDA from 1996 to 2000. This analysis allowed us to highlight problems related to the use of coronary stents by means of the analysis of these reports at different levels, beginning from the causes that can lead to a certain type of accident up to the possible complication related to that event. Moreover we analyzed the procedure outcomes in terms of stent position inside the patient's body and the possible therapies adopted to solve the problems. The results showed that the most probable event that can lead to an accident is the stent separation from the balloon which, alone, turns up in a number of cases equal to the sum of all the others.

This result highlights the importance of the technical skill of the operators accomplished by special training and of the importance of clarity and completeness in the instructions for the use of the device. Another critical point is the reliability of the device which must guarantee an adequate safety level when it is used according to the instructions.

Case Report: STENT DISLODGEDMENT

Male 61 years old who presented with stable angina since 1 month ago, with Risk factor of CAD: hypertension, Dyslipidemia and heavy smoker. The ECG showed inferior old myocardial infarction. Diagnostic coronary angiography found: bifurcatio lesion at distal LMCA with significant stenosis 60% at the distal LM and 85% at the osteal LCx (Medina score 1-1-0), high D1 and diffuse disease with maximal stenosis 85% at the distal LAD after D2, Significant stenosis 85% at the osteal LCx and CTO at the distal after OM1, diffuse disease with maximal stenosis 85% at the mid RCA. A 6-Fr JR 4.0 guiding catheter (Launcher, Medtronic) was engaged into the right coronary artery ostium via the femoral artery. GW pilot 50 (Hi-Torque Pilot 50) inserted to distal RCA. Perform Balloon support by Saphire II inserted to mid RCA and dilated, after that perform balloon to proximal RCA and dilated. Stent DES Firebird II (Rapamycin) to mid RCA and dilated. Stent BMS Apollo 3.0x36 mm inserted to proximal-mid RCA, overlapping with previous stent, but was loss or dislodged and insert to the guiding catheter. BMS stent was pulled out with small balloon ex stent. GC 6F 4.0 inserted to ascending Aorta and engaged at ostium RCA. BMS stent Arthos PICO 3.0x 34 mm inserted to proximal-mid RCA, overlapping with previous stent and dilated. Final angiography confirmed successful pull out of loss stent and dilation of the RCA.

Coronary artery stent dislodgement and aortic dissection in a patient with a severely calcified lesion in the proximal right coronary artery

In atherosclerosis progression, calcium deposition may have an impact on the natural history of coronary atherosclerosis, and the amount of calcium may affect the success rate of percutaneous coronary intervention (PCI). Coronary stent dislodgement does not commonly occur in the modern PCI era; however, it may lead to fatal death. If it occurs, retrieval of a dislodged stent can be performed either surgically or percutaneously using a variety of retrieval techniques, including inflating a catheter balloon distal to the undeployed stent, twirling 2 wires around the stent, a loop snare, or forceps. Here, we report a rare case that coronary artery stent dislodgement and aortic dissection simultaneously occurred during PCI for a severely calcified lesion in the proximal right coronary artery with shepherd's crook morphology. The situation was successfully rectified by using balloons to deploy the stent, as well as by applying an additional stent and minimizing the contrast used to treat aortic dissection. Learning objective: During percutaneous coronary intervention (PCI), stent dislodgement and aortic dissection are extremely rare, but life-threatening complications. In this rare case of simultaneous stent dislodgement in the coronary artery and aortic dissection during PCI for a severely calcified lesion in the right coronary artery with shepherd's crook morphology, the situation was successfully rectified by using balloons to retrieve and deploy the stent, as well as by applying an additional stent and minimizing the contrast used to treat aortic dissection.

A case of anterior communicating artery aneurysm successfully treated after a stent migration during stent assisted endovascular coil embolization

Stent migration is a complication associated with endovascular coil embolization of intracranial aneurysms. We report a case of anterior communicating artery (ACoA) aneurysm that was successfully treated after stent migration during endovascular coil embolization without retrieval of the stent. A 47-year-old man presented with sudden onset severe headache. Patient was noted to have subarachnoid hemorrhage from a ruptured ACoA aneurysm. Emergency endovascular coil embolization was performed. The second coil embolization was scheduled for the neck-remnant portion with a stent after 16 days from the initial operation. At first, a stent was deployed from the right perpendicular division of anterior cerebral artery (A2) to the left horizontal division of anterior cerebral artery (A1) entirely across the aneurysmal neck. Although the stent position looked fine, the stent migrated inferiorly to the proximal A1 portion when its delivery wire was withdrawn. Fortunately, the stent could be pushed into the distal A1 portion, when we trying to re-access the aneurysm thorough the stent with a pig-tail shaped microguidewire. Additional coil embolization was achieved using the assistance of distal tip of the stent as a scaffold of the coil. The patient was discharged without any complication on the postoperative day 6. Although there are various choices of rescue treatment after stent migration, this is the first reported case of stent repositioning with a microguidewire. Our technique may represent an effective option in case of stent migration.

A case complicated by floating fractured stent 141 months after nitinol stent implantation in the superficial femoral artery

An 80-year-old man received the implantation of a self-expanding stent (Luminexx, Bard, Inc., Murray Hill, NJ, USA) for an in-stent restenosis (ISR) lesion in the superficial femoral artery. However, angiography 141 months after the Luminexx stent implantation showed 90% ISR and a floating fractured stent in the Luminexx site. Furthermore, the floating fractured stent strut itself was completely separated and flowed toward the posterior tibial artery. The stent strut was removed by a catheter for removing intravascular foreign substances. <Learning objective: We report a case of a floating fractured stent 141 months after stent implantation in the superficial femoral artery (SFA). Although this case is rare, in endovascular therapy with stenting for SFA, it is necessary to consider the risk of stent fracture in the very late phase.>.

Stent loss during chronic total occlusion percutaneous coronary intervention: Optical coherence tomography-guided stent 'crushing and trapping'

Stent loss during percutaneous coronary intervention (PCI) is a rare event, which however has been associated with devastating consequences. Adequate management of this complication requires an exact understanding of the location of the lost stent and underlying mechanisms. Our case reports on a 55-year-old man who underwent PCI to a chronic total occlusion of the left anterior descending artery, complicated by stent loss. Successful management involved crushing and trapping of the stent behind a newly implanted stent. The use of optical coherence tomography proved invaluable, clarifying the relationship of the lost stent with side branches, allowing choosing a larger balloon for stent crushing, and suggesting a possible cause for stent loss. Finally, we provide a review on recent literature on stent loss during PCI and offer an algorithm to guide its management.

Lessons learned from acute and late scaffold failures in the ABSORB EXTEND trial

AIMS

Bioresorbable scaffolds are increasingly used in patients with coronary artery disease undergoing percutaneous coronary interventions. ABSORB EXTEND is an ongoing study that will recruit 800 patients. This report evaluates acute and late scaffold failure in the first 450 patients enrolled in ABSORB EXTEND who have completed 12 months follow-up.

METHODS AND RESULTS

Clinical event data from the first 450 patients enrolled in ABSORB EXTEND have demonstrated low rates of ischaemia-driven MACE (4.2%) and target vessel failure (4.7%) at 12 months. There have been seven cases of device failure in this study: three cases of scaffold dislodgement (0.67%) and four cases of subacute or late scaffold thrombosis (0.89%). All scaffold dislodgements occurred in the left circumflex (LCX), and in two cases dislodgement was observed after reinsertion of the same device. Two cases of subacute scaffold thrombosis and two late scaffold thromboses were observed. Two out of four cases of scaffold thrombosis seemed to be related to either premature discontinuation of dual antiplatelet therapy (DAPT) or resistance to clopidogrel.

CONCLUSIONS

This is the first report specifically describing the incidence and the potential mechanisms of scaffold dislodgement and scaffold thrombosis as seen in the ABSORB EXTEND trial.

Stent loss in the radial artery - surgical vs. interventional approach - report of two cases

Stent loss during coronary angioplasty is a complication that can be managed in various manners; however, transradial access limits the options available. We describe two coronary interventions complicated by stent dislodgement, initially managed by pulling the stent back to the radial artery. Both stents were unwillingly lost on different levels in radial arteries. The first case was managed with a direct radial artery cut-down because distal location made it a quick and straightforward procedure. In the second case a partially deployed stent was lost in the proximal part of the radial artery. It was rewired, deployed, and post-dilated with a larger balloon. This enabled continuation of the procedure using the same access. Both cases were asymptomatic during 24 months of follow-up. It is crucial to avoid leaving artificial bodies in arteries supplying vital organs because stent-related thrombosis or stenosis may seriously compromise blood flow. Removing the stent via the introducer sheath should be considered the optimal treatment. Unfortunately it is common that a partially expanded stent will not pass through the sheath. The superficial location of the distal radial artery segment facilitates surgical cut-down with local anaesthesia. When dislodgement occurs in deeper segments of the radial artery, the benefits from cut-down seem to be less because the procedure might take more time and be more difficult - as in the presented case in which we decided to rewire and fully expand the stent in situ. Retrieval of the stent at all costs might have led to further complications; hence stent deployment may be a good alternative to retrieval in such cases.

Stent dislodgement induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome

Coronary stent dislodgement is a rare but critical complication of percutaneous coronary intervention. It can potentially result in serious consequences, such as stent embolization and emergent coronary artery bypass graft surgery. Here, we describe the successful retrieval of an extracoronary dislodged stent, where dislodgement was induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome.

Myocardial infarction due to intracoronary embolization of percutaneous coronary intervention packaging

Intracoronary device loss is occasionally encountered and removal is commonly performed at the time of the procedure. We report a case of removal of a retained coronary balloon protective plastic tubing inadvertently left in the coronary artery for a month and associated with myocardial infarction. Optical coherence tomography was used to visualize the foreign body prior to removal with a snare. To our knowledge this is the first report of a removal of disposable packaging equipment after prolonged intracoronary dwell time.

Surgical retrieval of entrapped coronary angioplasty guidewire from the aorta

An entrapped or retained coronary angioplasty guidewire is a rare but serious complication of coronary interventions. A failed percutaneous transluminal coronary angioplasty attempt on the left anterior descending artery in a 35-year-old man was complicated by entrapment of the guidewire. Under cardiopulmonary bypass and cardioplegic arrest, the whole length of the entrapped guidewire was retrieved successfully from the left anterior descending artery and the aorta through an aortotomy following revascularization with left internal mammary artery.

Successful transradial removal of an inflated coronary stent dislodged from the right coronary ostium

We describe our solution to the unusual situation of an inflated, large coronary stent (3.5 mm diameter) which became dislodged from the ostium of the right coronary artery after deployment during a transradial procedure. We discussed tips for retrieval from the radial artery while preserving the access for completion of the procedure.

Stent entrapment and guide wire fracture during percutaneous coronary intervention in the same patient

In the performance of increasingly complex PCI there remains an ever-present risk of stent entrapment and guide wire or other device fracture. We report the first case with stent dislodgement and guide wire fracture to occur simultaneously in the same patient.

Two dislodged and crushed coronary stents: treatment of two simultaneously dislodged stents using crushing techniques

Coronary stent dislodgement is a rare complication of percutaneous coronary intervention. We report a rare case of dislodgement of two intracoronary stents. On withdrawal of two balloon catheters, one with a guide wire was mechanically distorted from the left main (LM) to the proximal left anterior descending artery (LAD) while the other was dislodged from the LM to the ostial left circumflex artery. The stent in the LAD could not be retrieved into the guide catheter using a Goose neck snare, because it was caught on a previously deployed stent at the mid LAD. A new stent was quickly deployed from the LM to the proximal LAD, because the patient developed cardiogenic shock. Both stents, including a distorted and elongated stent, were crushed to the LM wall. Stent deployment and crushing may be a good alternative technique to retrieving a dislodged stent.

How should I treat stent dislodgement in a STEMI patient resulting in dissection of left main and left circumflex arteries?

BACKGROUND

A 52-year-old female presented with acute anterior ST-elevation myocardial infarction (STEMI) within one hour of symptom onset to the emergency department. She was referred for urgent primary angioplasty.

INVESTIGATION

Physical examination, laboratory investigations, ECG, urgent percutaneous coronary intervention (PCI).

DIAGNOSIS

Single-vessel coronary artery disease (SVD).

TREATMENT

Intended to stent culprit lesion. However, stent dislodged in left main coronary artery (LMCA) during attempted PCI to diffuse mid segment of left anterior descending (LAD). Initial attempt failed to retrieve the dislodged stent with snare. Dislodged stent removed with multiple wire technique, complicated by severe dissection in LAD and left circumflex artery back into the LMCA. The stent was trapped at tip of 6 Fr right femoral sheath, unable to be withdrawn. What next?

Successful coronary stent retrieval from the ascending aorta using a gooseneck snare kit

Coronary stent dislodgement is a rare complication of percutaneous coronary intervention. We report a case of stent dislodgement in the ascending thoracic aorta. The stent was mechanically distorted in the left circumflex artery (LCX) while being delivered to the proximal LCX lesion. The balloon catheter was withdrawn, but the stent with the guide wire was remained in the ascending thoracic aorta. The stent was unable to be retrieved into the guide catheter, as it was distorted. A goose neck snare was used successfully to catch the stent in the ascending thoracic aorta and retrieved the stent externally via the arterial sheath.

Coronary stent embolization of peroneal artery

Embolization of coronary artery stents is a rare but well-recognized complication of percutaneous coronary intervention. Although intracardiac stent migration carries a significant risk to the patient, peripheral embolization is largely benign despite carrying a theoretical risk of distal ischemia. Furthermore, stents lost to the periphery are often never found. Here, we describe a case of an embolized stent to the peroneal artery which was accurately located using on-table fluoroscopy and ultrasound duplex.

Complications of coronary intervention: device embolisation, no-reflow, air embolism

The introduction of drug-eluting stents, better equipment, stronger antiplatelet drugs, and higher levels of operator experience has led to markedly improved patency rates for complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate complications. However, rigorous preventive measures pre-empt the appearance of complications. During traversal of severely diseased coronary arteries and manipulating equipment, particularly devices with detachable components, the opportunity for loss or embolisation of material in the coronary circulation presents itself. Device embolisation is associated with periprocedural myocardial infarction and emergent referral to surgery, particularly if the device is not retrieved. The coronary no-reflow phenomenon is a feared complication of PCI. It is associated with a worse prognosis and has been shown to be an independent predictor of death, myocardial infarction and impaired left ventricular function. Air embolism can be prevented by flushing of catheters during equipment exchanges.

Approaches for dislodged stent retrieval during transradial percutaneous coronary interventions

Transradial percutaneous coronary intervention (PCI) has been associated with a lower incidence of major access site related complications. With the increased implementation of transradial approach in complex PCI, stent dislodgement is unavoidable in any interventionalists' career. Stent retrieval is different in a transradial approach as compared to a transfemoral approach because of the former's smaller arterial size. In this review, we outline the different stent retrieval techniques with considerations from transradial access.

Dislodged and mechanically distorted stent stuck within a previously implanted drug-eluting stent

Coronary stent loss during percutaneous coronary intervention is rare and is often associated with significant morbidity. Several retrieval techniques, overlying stent deployment and crushing, and surgical removal can be used to deal with a stent lost in the coronary system. We successfully treated a dislodged and mechanically distorted coil stent stuck within a previously implanted drug-eluting stent (DES) by stent-crush technique. This case might provide insight into the mechanisms responsible for the longitudinal fragility of cobalt alloy and coil-structure stents and stent fracture of DES. In the DES era, careful attention should be paid to such complications when attempting to deliver a stent to a distal vessel through a pre-existing DES.