A 58-year-old male patient, a heavy smoker who presented to an outside hospital as a case of anterior ST-elevation myocardial infarction, was referred to our hospital for rescue percutaneous coronary intervention after failed thrombolytic therapy. Coronary angiography and successful rescue PCI were performed, but while trying to reopen a diagonal branch that was occluded after stenting the left anterior descending coronary artery, an unexpected complication occurred, which was managed successfully. This case reveals the importance of proper procedural planning, as well as the importance of imaging-guided coronary intervention specifically, should complications occur.
A 58-year-old male patient who was known to be a heavy smoker presented to a non-percutaneous coronary intervention (PCI) capable hospital with chest pain for 3 hours and stable hemodynamics. An electrocardiogram (ECG) showed anterior ST-elevation myocardial infarction (STEMI). Due the COVID-19 pandemic, the decision was made to give thrombolytics, then to refer the patient to our hospital for PCI after clearance by the COVID team.
On a follow-up ECG at 90 minutes after thrombolytic therapy, the patient had persistent, ongoing chest pain with unresolved ST-elevation on the ECG. The patient was referred to us and taken immediately to the cardiac catheterization lab for rescue PCI.
Coronary angiography was done via a right radial approach and revealed a subtotal occlusion of the mid LAD just after a major septal branch at the diagonal bifurcation with Medina classification 1:1:1, minimal irregularities of the left circumflex (Cx), and a dominant right coronary artery (RCA) with moderate plaque just before the crux (Figure 1A-C).
The decision was made to proceed with PCI to the LAD (culprit vessel) with a provisional stenting approach, given that the diagonal was small and had a 95% stenosis at its ostium; however, we elected not to wire the diagonal branch, since plaque shift and any resulting occlusion could occur, although it was expected in this case due to the shallow angle and high-grade stenosis at the ostium of the side branch.
Using an 6 French Extra Backup (EBU) 3.5 guiding catheter (Medtronic), we wired the LAD using a Balance Middleweight (BMW) wire (Abbott Vascular), predilated with a 2.0 mm x 15 mm balloon, and deployed a 3.0 x 18 mm drug-eluting stent (DES) at nominal pressure. The diagonal branch became occluded due to plaque shift. We post-dilated the stent using a 3.5 x 12 mm noncompliant (NC) balloon, resulting in good stent expansion in the LAD, but an occlusion in the diagonal branch (Figure 2).
Unfortunately, the patient developed chest pain with ECG and hemodynamic changes that did not resolve after sedation and intracoronary nitroglycerin, so the plan changed to an attempt to rescue the diagonal. Wiring the diagonal was not easy and the LAD wire unfortunately came back proximal to the stent. While attempting to wire the diagonal, the patient’s chest pain became worse and he became hypotensive. Angiography revealed that the LAD had become occluded at the proximal portion of the stent with TIMI-0 flow (Figure 3). Multiple attempts to buckle the wire through the stent were made, with eventual success. Multiple balloon dilations were performed, intracoronary adenosine was given, and a final TIMI-3 flow was achieved in the LAD. However, looking carefully at StentBoost (Philips) imaging showed that the wire was below the stent in the very proximal portion and then passed through the stent lumen. Also, the proximal stent portion was deformed, lifted up, and its inflow was pointing superior towards the vessel wall. The inferior portion of the vessel wall was not covered (Figure 4).
As the patient was hemodynamically stable with TIMI-3 flow, we elected to stop the procedure and transferred him to the cardiac care unit (CCU) on therapeutic heparin and a tirofiban infusion, as stent deformation can be a contributing factor to stent thrombosis (Figure 5).
The case was discussed in an interventional cardiology meeting. We planned to take the patient back to the catheterization lab the next day in order to fix the stent deformation. The following possible approaches were put forward for consideration:
- Attempt to extract the stent by snaring it. A very risky approach, possibly creating increased endothelial injury, injuring the left main, and/or causing a dissection.
- Attempt to wire through the entire stent length and fix the deformation with either balloon and/or stent.
- Wire from above the stent proximally and push the deformed portion inferiorly, while having another wire through the stent to maintain access and fix the deformation (considered non feasible).
- Wire from above and below, squeeze the stent between two balloons, extract the stent with a balloon distally, and deploy a new stent.
- Wire behind the stent proximally, then through it, and crush the deformed portion with a new stent with the use of intracoronary image guidance.
We elected to move forward with this final option, since it was thought to be the safest and easiest approach. Optical coherence tomography (OCT) showed the stent to be well opposed distally, but surprisingly, there was stent fracture with deformed stent proximally and the stent was elongated (Figure 6A-B).
At this time, we were able to pass through the true stent lumen and perform multiple balloon inflations, crush the stent proximally, and stent proximally in an overlapping manner. Final angiography showed an excellent result (Figure 7A-C), as did OCT (Figure 8).
This case showed the importance of maintaining wire position in the primary vessel even after experiencing a positive initial result. While attempting to wire the diagonal, most likely thrombi were dislodged to the distal bed, making the situation worse. We reported this case in order to share knowledge with our colleagues, demonstrate how we dealt with this complication, and describe how to avoid such a complication in the future. This case also demonstrates the importance of imaging-guided coronary intervention. Planning remains the most important step in any coronary intervention.
The authors can be contacted via Dr. Mosa Abbadi at firstname.lastname@example.org
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