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Patient initials or identifier number
Relevant clinical history and physical exam
The patient is 50 years old smoker, non-hypertensive on-diabetic gentleman. He was not on any medications previously. He developed severe retrosternal angina and was diagnosed with ST elevation anterior wall myocardial infarction. He was administered streptokinase and referred to this center for revascularization. On presentation, the patient was in mild pain. Hemodynamic parameters were satisfactory. There was no sign suggestive of pulmonary edema.
Relevant test results prior to catheterization
ECG before thrombolysis showed ST elevation in V2-V5. post-thrombolysis, there was significant ST resolution.
Echocardiography showed hypokinesia in LAD territory with LVEF of 45%.
Relevant catheterization findings
The coronary angiography showed a discrete lesion in mid-distal LAD involving the second diagonal branch. The second diagonal was less than 2.5 mm in diameter. The RCA and left circumflex arteries had minor plaques only.
Right radial access was taken. A 6FXB 3.0 guide catheter was taken. Run through Hypercoat wires were taken across distal LAD and D2 branches. The lesion was predilated with Tazuna 2.0 x 10 mm balloon at 10 atmospheres. Promus Element Plus 3.5 x 28 mm stent was deployed at nominal 11 atmospheres. There was difficulty taking 3.5 x 12 noncompliant balloon across stent, possibly because of wire entanglement. The diagonal wire was, pulled out gradually. However, a resistance felt and fluoroscopy showed that the proximal part of stent had become stretched out and distorted. Next multiple balloons of 1.5 mm; 1.25 mm and 1.0 mm were taken across the diagonal wire to dilate the stent struts away from the wall. The diagonal wire was then successfully taken out with gradual traction. Care was taken to keep LAD wire in place in distal LAD. Semi-compliant 2.25 and 3.0 mm balloons were then taken across LAD wire and inflated to correct distortion. Finally, a 3.5 x 38 mm Promus Element Plus stent was taken across LAD wire. This was precisely positioned proximally at the LAD ostium proximally and deployed at nominal pressures. Post-dilatation was done with 3.5 x 8 mm non-compliant balloon at 18 to 20 atmospheres. TIMI III flow was achieved.
The patient had an uneventful hospital stay and was discharged after two days.
It was rather surprising to find stent distortion secondary to removal of jailed wire. This was in spite of the fact that post-dilatation or proximal optimization was not done. At this time, it is imperative that the distal wire stays in place as inadvertent removal of this wire will make all salvage efforts futile. This is because of difficulty in taking wire across lesion through distorted struts. The patient may have to be sent for emergency bypass surgery, which carries its attendant risk in the setting of ST-elevation myocardial infarction.
Removal of jailed wire can facilitate by dilating stent struts away from the wall, as shown in this case. Side branch may close after stent deployment.