Author + information
- Polpat Euswas1
Patient initials or identifier number
Relevant clinical history and physical exam
A 46 years old, female, DM type 2, HT, DLP, Active smoker
Past history : 1 year ago Dx: Chronic stable angina, positive EST, CAG: TVD
Previously denied any operation (PCI or CABG)
Present illness : Progressive dyspnea on exertion 1-2 mo.
BP 135/84 mmHg, HR 65/min, RR 18/min
Heart: no murmur, Lungs: Clear, Legs: No edema
This time, she want to do PCI, strongly denied CABG.
Relevant test results prior to catheterization
EKG 12 leads showed sinus rhythm without significant ST-T segment abnormality.
Relevant catheterization findings
CAG: Left coronary system showed significant stenosis at proximal to mid LAD, tight stenosis with small caliber at distal LAD, stenosis at ostial to proximal the first diagonal branch, small size of left circumflex artery
Right coronary showed stenosis at proximal part and ostial PDA
1. FFR at RCA and DG1
RCA: FFR=0.90, 0.83 resting, adenosine 200 microgram IC.
DG1 FFR=0.81, 0.74 resting, adenosine 100 microgram IC.
2. PCI at LAD and DG1 lesions.
Guiding : EBU 3.5/6Fr
GW: Fielder FC to LAD, pressure wire to DG1
Balloon dilatation at distal to proximal LAD: Trek 2.0 / 15 mm, 8 – 14 atm.
Balloon dilatation at proximal to ostial DG1 : Trek 2.0 / 15 mm, 8 – 10 atm.
Stent ULTIMASTER (DES) 2.5 /15 mm, 14 atm
at mid LAD.
Stent DG1 ULTIMASTER (DES) 2.25 /18 mm. 8 atm.
at ostial to proximal DG1
PROBLEM I COULD NOT PASS the next DES 2.5/18 mm, to mid LAD lesion
Need to removed stent out BUT FELT SOME DIFFICULTY
The stent was dislodged in left main coronary artery
Strategies plan : Low profile balloon, Myocardial biopsy forcep, twisted wire technique, etc.
I selected twist wire technique with Run through and BMW-Universal II guide wires.
3. Twisted wire technique procedure
Inserted Run through and BMW-U-II guide wires into LAD and locked 3 wires all together with talker.
Released the connector pressure.
Twisted all wires in one direction, until the dislodged stent was moved.
Then pull the whole system out
Finally, successful procedure.
4. Continued PCI at the proximal to mid LAD lesion
Adequate predilatation with Balloon NC 2.5 / 15 mm, 20 atm
Stent ULTIMASTER (DES) 2.5 / 18 mm., 14 atm.
The Stent dislodgement
1. Risk factors
Arterial tortuosity and calcification
Poor guide support
Operator’s experience and strategy
2. Various percutaneous retrieval techniques
Low profile angioplasty balloon catheter
Myocardial biopsy forceps
Two twisted guide wires to entrap dislodge stent
Compressing and crushing the dislodged stent against vessel wall
3. Tips and tricks of twisted wire technique
Selected another two non-hydrophilic guidewires
Inserted all wires in talker and lock
Twist all wires with talker in one direction, continue twist until feel the stent move and then pull the whole system out.