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Relevant clinical history and physical exam
We presented a 64 year-old man known for diabetes, hypertension, dyslipidemia and smoking. History of previous inferior infarction treated by primary PTCA with BMS on RCA in 1998. Admitted in July 2016 for unstable angina treated with DES on CX. For residual stenosis on his LAD he was readmitted after one month for further diagnostic evaluation. During this month the patient was completely asymptomatic.
Relevant test results prior to catheterization
At his readmission for LAD planned reinvestigation as mentioned above he was completely asymptomatic. His ECG was within the normal range and his echocardiogram exam demonstrated moderate inferior hypokinesia with normal EF. Normal was also his general lab exam. During the exercise test there was no ECG signs of ischemia, but the patient referred typical chest pain. At this point, he was planned for coronary angiography and eventual LAD PTCA after FFR evaluation.
Relevant catheterization findings
Angiography through 6F right radial artery revealed patency of the previous RCA and LCx stenting. LAD presented calcified moderate stenosis at it's proximal to mid part followed by second one. Basal FFR 0.79. Unsuccessful tentative of stent placement was made after predilatation with compliant balloon. When the stent was removed from the guiding catheter the stent was not seen on it's balloon, but it was freely rotating in the coronary sinus.
Tentative with 20 mm snare was made to retrieve it, but the stent migrate in the thoracic aorta. Due to chest pain LAD was stented with two DES in overlapping with the use of catheter extending system with final FFR 0,89. Then through the right radial catheter new tentative for retrieval of the lost in the aorta stent was made - but also this time without success. Through the second access - right femoral we were able to catch the stent with Goose neck 20 mm while blocking it from above with a pigtail from radial artery and remove it trough the femoral sheath. The patient then was transferred in CCU and 10 min later he referred intensive chest pain and ST elevation in all anterior leads. Urgent coronarography performed through the femoral sheath revealed acute instent LAD occlusion. Intracoronary IIb/IIIa inhibitors, thrombus aspiration and thrombus fragmentation with different compliant and non compliant balloons were made. For persistent intrastent minus another DES was placed inside the first one. The final result was TIMI 2 and Blush 2. Infusion with IIb/IIIa inhibitor was stopped due to gastrointestinal bleeding. Several blood transfusions were made. At the femoral access site, the patient developed hematoma with extension within the retro peritoneal space that was treated surgically. One month later he was discharged with QS waves from V1 to V6, left ventricular aneurism, severe reduction of his EF (25%) and signs of moderate heart failure.
This case demonstrates the crucial importance of lesion preparation with the aim to achieve almost stent-like result before final stent placement.This preparation includes use of non-compliant balloon, scoring balloons or cutting balloons and in some case debulking techniques to reduce the problems of incomplete stent delivery or stent lost.
To take in consideration also the usage of catheter extension systems to avoid such stent lost.
Extreme importance should be taken to have wide range of appropriate devices to face the most frequent complications.