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CASE REPORT
Year : 2023 | Volume
: 24
| Issue : 3 | Page : 157-159
Slippage of an undeployed stent in the left main artery: A case report study
Abdelaziz Ahmed Abdelaziz1, Ahmed Maher Abo Taleb2
1 Department of Cardiology, Teachers Hospital, Cairo, Egypt
2 Department of Cardiology, Cairo University, Cairo, Egypt
Correspondence Address:
Dr. Abdelaziz Ahmed Abdelaziz
Teachers Hospital, Mahmoud Mokhtar Street, Zamalek, Cairo
Egypt
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_120_22
Abstract
Advances in stent design and technology have made stent loss during percutaneous coronary interventions rare. When an undeployed stent dislodges in the left main (LM) artery during percutaneous coronary angioplasty, the risk of life-threatening procedural complications is high. We report a 50-year-old male patient, a smoker, with a history of diabetes mellitus and hypertension with typical chest pain on minimal exertion. Electrocardiogram and echo revealed ischemic changes and regional wall motion abnormality. Culotte technique was used. A new 3 mm × 48 mm stent was inserted in the LM-left circumflex (LM-LCX) followed by stenting of the LM-left anterior descending (LM-LAD) ostia with a 3.5 mm × 18 mm stent. The two balloons were rewired and kissed. Stent slippage and dislodging in the LM artery can be corrected using the culotte technique to crush the undeployed stent behind the LM-LCX and LM-LAD stents.
Keywords: Culotte technique, left anterior descending artery, left circumflex artery, left main artery, stent slipping
Introduction 
One of the rare complications of percutaneous angioplasty is the slippage or dislodgment of an undeployed stent from its balloon in the left main (LM) artery. Stent dislodging and entrapment of the guiding wire are possible risks that affect the blood flow in the LM artery. Slipped stents might be an indirect cause of serious cardiovascular diseases,[1] such as mesenteric ischemia, myocardial infarction, and stroke, by increasing coronary perforation and dissection. The risk increases as the dislodged stents cannot be deposited after deployment. However, the main reasons for that situation (stent dislodgement) are not yet confirmed, some factors such as small sizes or poor-quality stents, over calcification of blood vessels (meaning that the coronary arteries might be highly calcific), and vascular tortuosity might be associated.[2] Multiple techniques were applied to retrieve the dislodged stents, such as loop snares, balloon catheters, or crushing of dislodged stents.[3] Here, we report a complicated case of stent dislodgment in the distal LM. Written consent was obtained from the patient.
Case Presentation A 50-year-old Egyptian male presenting with unstable angina was admitted to the Cardiology Department of the Teachers Hospital. The patient suffered from other comorbidities including diabetes mellitus (DM), hypertension (HTN), and dyslipidemia; in addition, he was also a smoker. The patient complained of having typical chest pain on minimal exertion for the past 3 months. The diagnosis of the case by the electrocardiogram revealed an inverted T-wave from V4–V6. Furthermore, the echo showed regional wall motion abnormality in the form of the hypokinetic mid and basal lateral wall.
The coronary angiography was performed using the transradial approach, and it revealed that the LM had an average size and bifurcated into the left anterior descending (LAD) and left circumflex (LCX) arteries without any significant lesions. LAD showed obvious atherosclerosis with proximal total occlusion and retrograde filling from the right coronary artery (RCA) [Supplementary Figure 1]a. LCX was also atherosclerotic and branched into two obtuse marginal (OM) branches with proximal insignificant lesions at the bifurcation. OM1 had a proximal significant lesion, whereas a mid-significant lesion in 80% of OM2 was diagnosed [Supplementary Figure 1]b. Similarly, RCA appeared as an atherosclerotic dominant vessel with no significant lesions and gave retrograde filling to the LAD [Supplementary Figure 1]c.
The patient underwent urgent coronary angioplasty. During the procedure, LM was engaged using guiding catheter XB 6F (Cordis), and PT2™ wire (Boston Scientific) was used to cross the totally occluded LAD and parked distally, followed by predilatation of the LAD lesion. This was performed by a Mini Trek balloon (Abbott) balloon (2 mm × 15 mm), which was inflated up to 10 atm [Supplementary Figure 2]a. First, stenting of the proximal LAD lesion was done using Xience Alpine stent (3 mm × 38 mm) (Abbott) and was inflated up to 16 atm with excellent separation of the struts [Supplementary Figure 2]b.
The stenting of the distal LAD lesion was done by a Resolute Integrity stent system (2.25 mm × 18 mm) (Medtronic), resulting in excellent separation of the struts, which was confirmed by the coronary angiographic images [Supplementary Figure 3].
To manipulate the LCX lesions, the same PT2™ wire was used to cross LCX proper lesion and parked distally [Supplementary Figure 4]a. Then, an Ultimaster drug-eluting stent (DES) (Terumo) of 2.5 mm × 15 mm was used. As shown in [Supplementary Figure 4]b, the stent failed to cross the ostium of the LCX and most probably slipped from its balloon in LM. That might be due to the stent friction with the previous ostial LAD stent [Supplementary Figure 4]b.
We tried using the snare to capture the slipped stent, but it failed. After a short discussion with the team, the decision was to use the culotte technique in the LM in order to ensure the full coverage of the dislodged stent. At first, we replaced the guiding 6F catheter with another 7F XB 3.5 guiding catheter. Then, the LCX PT2™ wire was placed in a large OM branch, whereas a BMW wire (Abbott) was placed distally in the LAD. The stenting of the LM-LCX was performed using a new Xience Xpedition stent (3 mm × 48 mm) (Abbott), and then, the LAD was rewired with another PT2™ wire [Supplementary Figure 5]a. The LAD was predilated by a Mini-trek (2 mm × 18 mm) balloon [Supplementary Figure 5b].
The LM-LAD ostium was stented with a Xience Alpine DES (3.5 mm × 18 mm) that was inflated at 18 atm [Supplementary Figure 6]a. Following that, the LAD was rewired and the balloons were kissed [Supplementary Figure 6]b. Finally, the proximal optimization technique was used in the LM using Accuforce percutaneous transluminal coronary angioplasty dilatation catheter (5.0 mm × 8 mm) (Terumo) [Supplementary Figure 6]c. The coronary angiography showed good results with normal Thrombolysis in Myocardial Infarction (TIMI) III flow in the left system [Supplementary Figure 6]d.
Discussion Stent dislodgment in the coronary intervention is most prevalent in LM, LAD, LCX, and RCA by 0.3% and 8%, despite the technological improvement of stent mounting.[4],[5] The causes for such complications are still not clear or unproven. This serious issue might increase the risk of intracoronary thrombosis and myocardial infarction.[6] There are several reported retrieval techniques for dislodged stents, such as the use of two wires around the stent, stent crushing, or inflating another catheter balloon at the distal end of the slipped stent.[5]
Here, we reported the usage of the longer stent (3 mm × 48 mm) for LCX lesions and rewiring the LAD with two wires to prevent the slipping of the stent. The LM-LAD was stented with another DES, followed by rewiring and proximal optimization of the LM using a noncompliant balloon with the dilatation catheter. Our final coronary angiogram showed good TIMI III blood flow in LM, which indicated successful crushing of the dislodged stent. A similar study used a successful bailout approach to retrieve a dislodged stent in the femoral vascular system, where they used a balloon-assisted retrieval method without the need to crush the slipped stent.[1]
Another report showed that the use of a shortened guide catheter and a 20 mm Amplatz Goose Neck snare (Medtronic) could retrieve the deformed stent during a transradial intervention.[7] In our report, we failed to capture the slipped stent with a snare, which might be due to its complicated position in the LAD-LCX bifurcation. Similar findings were reported by Yang et al., who failed to use the GooseNeck snare to retrieve the slipped stents in LAD and LCX arteries. However, in that report, they used the stent-crushing methods.[4]
In the case report conducted by Malik et al., they claimed that the stent crushing technique is the best option for stent dislodgment in the percutaneous coronary intervention (PCI) of the RCA.[8] However, several studies showed that both crush and culotte techniques had similar outcomes in cases of the dislodged stent in the coronary artery bifurcation lesions.[9],[10],[11]
Conclusion We report a case of slippage of a thin, cobalt chromium, sirolimus-eluting coronary stent from its balloon in the distal LM and encroaching on the ostium of the LCX. Successfully, we have crushed the dislodged stent using the culotte procedure which resulted in good coronary angiography images revealing a normal TIMI III flow in the LM-LAD and LM-LCX.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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