It’s a Trap: A Case of Strangulated Coronary Guidewire and Longitudinal Stent Deformation in the Right Coronary Artery

Abstract

Patient: Male, 62-year-old Final Diagnosis: Coronary artery disease • entrapped coronary guidewire • stent deformation Symptoms: Angina pectoris Medication: — Clinical Procedure: Angioplasty • coronary artery bypass grafting (CABG) Specialty: Cardiac Surgery • Cardiology Objective: Management of emergency care Background: Strangulation of the coronary guidewire is an infrequent complication of percutaneous coronary intervention (PCI), and it can lead to disastrous outcomes of stent thrombosis, vessel occlusion, and vessel damage. Case Report: Early-generation stents were made from stainless steel and had a bulky design as compared to cobalt-chromium or platinum chromium alloys, which have superior trackability at the cost of a thin core and low-strength struts, resulting in increased incidence of longitudinal stent deformation. We present a case of a 62-year-old active smoker with effort angina of Canadian Cardiovascular Society (CCS) class III. His coronary angiogram revealed a totally occluded right coronary artery (RCA). After placing 2 coronary guidewires (Run-through and Balanced middle-weight), Xience Xpedition (3.25×48 mm) and Promus Element (2.75×32 mm) were deployed through the whole length of the RCA. While placing the distal stent, the guidewire securing the posterior left ventricular (PLV) was trapped between 2 stents and all attempted maneuvers were unsuccessful in retrieving the wire. The stents sustained longitudinal deformation by the guide catheter, and subsequent arteriotomy for stent and wire retrieval and coronary artery bypass graft surgery were (CABG) performed. Conclusions: Despite the remarkable safety profiles of the percutaneous equipment, complications still occur even with experienced operators. Calcified and tortuous vessels are primarily at risk for wire strangulation between stents or side-branches, and better deliverability of newer drug-eluting stents (DES) comes at the cost of reduced longitudinal strength.

Unrecoverable stent deformation in the left main: Crush it or remove it?

“…Terms such as stent “explantation,” “retrieval,” “extraction,” or “avulsion” describe the same technique: the intentional or unintentional removal of a newly implanted or older, already endothelialized stent. Most reports of stent retrieval involve undeployed embolized stents—not to be confused with retrieval of fully deployed stents, which has been reported sporadically, with most of these cases being accidental 6–21 . We report a case of successful intentional retrieval of a previously implanted DES without relevant endothelial injury or vascular disruption and demonstrate that stent explantation may be a novel intention‐to‐treat concept that appears feasible when fighting with erroneously placed stents in aorto‐ostial locations.…”

“…Most reports of stent retrieval involve undeployed embolized stents-not to be confused with retrieval of fully deployed stents, which has been reported sporadically, with most of these cases being accidental. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] We report a case of successful intentional retrieval of a previously implanted DES without relevant endothelial injury or vascular disruption and demonstrate that stent explantation may be a novel intention-to-treat concept that appears feasible when fighting with erroneously placed stents in aorto-ostial locations. It must be acknowledged, however, that the safety of intentional retrieval of fully deployed stents has not been well described.…”