Article Type : Case Report
Authors : Thein HT, Fam JM, Wong A and Ho KW
Keywords : Coronary stent avulsion; Complication; Jailed pressure wire
We describe a case report of coronary stent avulsion by a jailed side-branch pressure wire. Diagnosis was confirmed by angiographic and intravascular ultrasound imaging. The avulsed stent was treated by crushing to the vessel wall by a second stent.
Provisional stenting is advocated as the default bifurcation
stenting technique which jails a side-branch wire. The jailed wire
keeps side-branch open and increases success of intervention if it
occludes . However, complications like jailed wire
fracture/unravelling, stent avulsion or vessel injury during jailed
wire retrieval may occur. Stent avulsion is a rare complication of
percutaneous coronary intervention (PCI) where stent segment is
displaced from original implantation site due to interaction with
intracoronary devices like guidewires or balloon catheters while
the intact stent segment remained in the intended area. The
avulsed stent becomes stretched and deformed . There is no
consensus for managing this complication. We describe a case
report of coronary stent avulsion during retrieval of an entrapped
side-branch pressure wire
A 60-year-old male with angina underwent coronary angiogram
which showed proximal to mid LAD diffuse disease (Figures 1
and 2). EBU 3.0 6Fr guiding catheter was used for LAD
fractional flow reserve (FFR) measurement using Pressure Wire
X (Abbott, IL, USA). FFR was 0.75. Stenting of proximal to mid
LAD was decided. LAD was wired with Sion Blue to provide
support to deliver a long stent and pressure wire was repositioned
to D2 (Figure 3). After predilatation, CRE8 Evo 2.75 x 46 mm
stent (Alvimedica, Turkey) was positioned in LAD using its
radiopaque markers. Stent was deployed (Figure 4) and postdilated with non-compliant 3.0 x 15 mm balloon. Satisfactory
result was achieved with proximal stent marker in proximal LAD
(Figure 5 and 6). Resistance was felt when removing the jailed
pressure wire. Pressure wire was successfully removed with
disengagement of guiding catheter and forcefully pulling on the
wire. Angiogram showed hazy defect in proximal LAD (Figure
7). Proximal stent marker was displaced to the left coronary cusp
(LCC) (Figure 8). LAD was rewired and dilated with 3.0 x15 mm
balloon. Intravascular ultrasound (IVUS) confirmed stent
integrity beyond D2. Stent was deformed proximal to D2. It
elongated through left main artery (LM) and protruded into LCC.
There was incomplete stent apposition and plaque protrusion in
proximal LAD (Figure 9). Examination of pressure wire showed
no missing segment. Decision was made to stent and crush the
deformed stent from ostial LM to mid LAD leaving a segment of
unraveled stent in LCC. This was a safer alternative to an
attempted snare retrieval of the stent with high likelihood of
vessel injury. Surgery was declined by the patient. To reduce the
likelihood of deformation of the second stent by the unraveled
stent, a 6F Boosting guider extension catheter was positioned in
mid LAD. A CRE8 3.5 x 46 mm stent was deployed from ostial
LM to mid LAD beyond D2. The stent was post-dilated with noncompliant 3.5 and 4.0 mm balloons (Figure 10). IVUS showed
that the second stent crushed the unraveled stent to the vessel wall
(Figure 11). A segment of avulsed stent remained beyond LM in
LCC. Patient was pain-free during procedure and was dischargedthe following day. He was prescribed lifelong dual anti-platelet
therapy (DAPT). He was reviewed in clinic after 6 months with
no angina or hospitalization.
Figure 1: Diffuse LAD stenosis (RAO Cranial).
Figure 2: Diffuse LAD stenosis (RAO Caudal).
Pressure wire positioned in D2. Ostial D2 stenosis (arrow).
Figure 4: Deployment of stent.
5: After stent deployment.
Figure 6: Proximal stent marker.