Guideliner related stent stripping Nagajothi, MD zulqarnain, MD Satti, MD Duffy, MD Malosky, MD Aultman Health foudation canton medical educatino canton, ohio

Nagapradeep Nagajothi, MD I/we have no real or apparent conflicts of interest to report. Off-Label: Use of a balloon catheter to try to retrieve a dislodged stent.

Case 1: 59Y/O Caucasian gentleman with h/o of coronary artery disease S/P CABG(x3) in 2005, Stents to proximal and mid RCA in 2008 and 2011 as well as mid LAD in 2012 presented with symptoms of unstable angina. Physical Examination was unremarkable. Cardiac markers were negative.

The guideliner catheter offers extra support and assists in stent delivery. However it is important to keep in mind that the inner diameter is smaller than the guide catheter and hence there is a chance of stent stripping. This is especially the case if there was a prior attempt at stent deployment since the stent could be distorted by the initial attempt. This could happen at both ends of the guideliner and caution should be exercised when entering or exiting the device. One of the options in such a case is to “preload” the stent into the guideliner outside the guide catheter.

Coronary angiography Left Main Coronary Artery had mild disease. LAD: 70% stenosis in the proximal and ostial portion. 80% stenosis of the mid LAD before it gives off the second diagonal. Immediately after the second diagonal there was 100% occlusion of the LAD.   LCx: 90% stenosis in the mid portion and 100% occlusion of OM1 at the ostium.   RCA: mild in-stent restenosis.  3/3 grafts were patent. (LIMA to LAD, SVG to OM1 and SVG to acute marginal)

PTCA of the mid left anterior descending was performed. Stent (Xience) did not cross the mid LAD stenosis Guideliner was used for additional support. The stent still did not cross. The stent catheter was removed but the stent was stripped at the distal end of the guideliner. Distal to the stent we inflated a 1.2 X 8 mm Mini Trek balloon and tried to withdraw the stent out.

The distal end of the stent got stuck on the guide and again went back to the left main. We successfully snared the stent out of the left main. However, as we were getting it out of the sheath, the stent embolized to the right popliteal artery. We decided to stop with the fair PTCA result we had and not to pursue further attempts to stent the mid LAD. The proximal LAD was stented.

Frame by Frame

  Then we went in through the left common femoral artery with the En Snare. We brought the stent back into the tip of the guiding catheter.   As we were pulling out the guiding catheter, again the stent embolized. This time it went to the proximal portion of the anterior tibial artery. With further attempts at snaring, the stent kept getting embolized more distally and finally it was stuck in the mid portion of the anterior tibial artery. We decided to terminate the procedure.  The patient was ambulating without any problems the next day and is stable on outpatient followup.

Case 2: 65Y/O Caucasian female with known history of coronary artery disease S/P stent to the right coronary artery in 2003 and first diagonal in 2005, CABG in 2004(LIMA to LAD, SVG to PLV, LCX and D1), hypertension, hyperlipidemia and DM II presented with symptoms of unstable angina. Physical Examination was unremarkable. Initial Troponin was 0.07ng/ml. Patient underwent cardiac catheterization.

Coronary Angiography culprit

We pre-dilated serially with a 2 We pre-dilated serially with a 2.5 x12 Trek balloon and on attempting to deploy the stent, we were unable to pass the stent because of proximal angulation in the diagonal branch. We tried a guide liner to assist .The Xience stent stripped from the balloon at the proximal end of the guideliner. We did get a reasonable angioplasty result decreasing the stenosis from 99% to approximately 50%. She did not have any hemodynamic complications. The stent was retrieved by removing the guide liner and guide catheter simultaneously.

Cardiac Catheterization the following day With the help of a guideliner once again we predilated the stenosis with a 2.5 x 15 Trek noncompliant balloon to 16 atmospheres and deployed a 2.5 x 12 Promus element stent and post dilated it with the same 2.5 x 15 balloon to 22 atmospheres.  

Discussion

Discussion The guideliner catheter offers extra support and assists in stent delivery. However it is important to keep in mind that the inner diameter is smaller than the guide catheter and hence there is a chance of stent stripping. This is especially the case if there was a prior attempt at stent deployment since the stent could be distorted by the initial attempt. This could happen at both ends of the guideliner and caution should be exercised when entering or exiting the device. One of the options in such a case is to “preload” the stent into the guideliner outside the guide catheter.