Asian Cardiovasc Thorac Ann 1998;6:240-241
© 1998 Asia Publishing EXchange Pte Ltd
Stent Entrapment in Ostium of Left Main Coronary Artery: Emergency Surgical Removal
Senol Yavuz, MD,
Tahsin Bozat, MD1,
Hakan Vural, MD,
Osman Tiryakio
lu, MD,
Tamer Türk, MD,
Nurcan Ayabakan,
Cüneyt Eris, MD,
Vedat Koca, MD1,
I Ayhan Özdemir, MD
Department of Cardiovascular Surgery
1 Department of Cardiology Bursa Yüksek Ihtisas Hospital Duaçinari, Bursa 16330, Turkey
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Intracoronary stenting is the definitive procedure after failed balloon angioplasty. It provides confirmed revascularization even when the target vessel has a severely calcified lesion leading to dissection or recoiling.1,2 With the increasing use of flexible intracoronary stents there has been a rise in related complications including stent misplacement, stent embolization, acute and subacute stent thrombosis, and an increased risk of major bleeding due to anticoagulation therapy.1–3 We report a case in which a balloon-expandable coronary stent was inadvertently dislodged from the coronary balloon catheter and became entrapped in the ostium of the left main coronary artery.
A 54-year-old man with unstable chest pain was referred to our cardiology department for an angiographic study. He was diabetic and hypercholesterolemic. His coronary angiogram revealed a long-segment concentric lesion of 95% narrowing in the proximal part of the left anterior descending coronary artery (LAD), 70% narrowing in mid-right coronary artery, and 30% narrowing in the proximal left circumflex artery. Elective percutaneous transluminal coronary angioplasty was carried out in these vessels. Residual stenosis in the LAD was greater than 50% due to elastic recoil. Because of threatened closure of the LAD, insertion of a balloon-expandable coronary stent, 26 mm in length and 3.5 mm in width, was attempted. Placement of the stent was unsuccessful and as it was being withdrawn, the unexpanded stent was dislodged from the coronary balloon catheter to the ostium of the left main coronary artery. The patient suffered ischemia, chest pain, bradycardia, and hypotension. Retrieval was not attempted for fear of stent loss in the ascending aorta and due to the patient's hemodynamic instability. It was decided to remove the stent surgically. An intra-aortic balloon pump was positioned and rapid induction of anesthesia and institution of cardiopulmonary bypass with moderate hypothermia were carried out. As the patient's condition was not stable, the left internal thoracic artery was not prepared. An aortotomy was performed on the ascending aorta. One third of the stent was in the lumen of the ascending aorta. The stent was successfully removed with forceps from the ostium of the left main coronary artery. Triple coronary artery bypass was performed using saphenous veins. Prompt revascularization of the LAD was achieved first. The saphenous vein grafts were used to deliver additional cold blood cardioplegia. The mean time from the onset of ischemia to revascularization of the target vessel was 35 minutes. The patient's postoperative course was uneventful and he was discharged on the 8th postoperative day. Angiography was performed 13 months later, all the grafts were patentand the patient was symptom-free and leading an active life.
Commercially available retrieval devices such as a gooseneck snare, biliary forceps, and a multipurpose basket have been recommended to operators involved in intracoronary stent placement.4 In this patient, removal of the stent by a transcatheter approach was avoided because of fear of dislodgement of the stent to the ascending aorta. Emergency coronary artery bypass grafting can be a life-saving procedure in such complications of stent deployment.5 We performed an aortotomy on the ascending aorta and successfully removed the stent with forceps before carrying out coronary artery bypass grafting to the LAD, the right coronary artery,and the left circumflex coronary artery. Erez and colleagues6 avoided anastomosis of the circumflex artery in similar circumstances. They used anticoagulation to minimize potential intimal damage for 3 months. We anastomosed the circumflex artery because we suspected that the left main coronary artery was traumatized during the attempted stent insertion. These conditions present a difficult problem and the treatment must be decided on an individual basis.
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