Trapped Stent in the Left Coronary Sinus in a Myocardial Infarction Patient

ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online)

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Department of Thoracic and Cardiovascular Surgery, Dankook University College of Medicine

Received: September 5, 2014, Revised: November 6, 2014, Accepted: November 7, 2014, Published online: October 5, 2015

Corresponding author: Pil Won Seo, Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Dankook University College of Medicine, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea

(Tel) 82-41-550-6269 (Fax) 82-41-550-6031 (E-mail) [email protected]

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The Korean Society for Thoracic and Cardiovascular Surgery. 2015. All right reserved.

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Trapped Stent in the Left Coronary Sinus in a Myocardial Infarction Patient

Sun Han, M.D., Pil Won Seo, M.D.

Stent entrapment is a very rare complication of percutaneous coronary intervention. The interventional approach could be a treatment strategy. However, if it does not work, surgical treatment should be considered. Here, we report a case of surgical treatment of stent entrapment in the left coronary sinus of a 53-year-old male patient.

Key words: 1. Coronary stent entrapment 2. Myocardial infarction

CASE REPORT

A 53-year-old male was admitted to the hospital with chest discomfort that had persisted for five days. His medical his- tory was unremarkable, except for a tuberculosis infection 10 years earlier. Elevated cardiac enzyme levels were observed, including 0.1 ng/mL of troponin T and 11.1 ng/mL of crea- tine kinase-myocardial band. Electrocardiography showed that the ST segment was elevated at the anterior lead. A chest X-ray showed pulmonary congestion. Transthoracic echocardiography revealed a reduction of the ejection fraction to 35%, with se- vere hypokinesis of the anteroseptal area. The patient was di- agnosed with myocardial infarction accompanied by pulmo- nary edema. Selective coronary angiography showed 90% ste- nosis in the proximal to mid-portion of the left anterior de- scending (LAD) artery. The lesion was long and irregular. We decided to insert two stents into the lesions. The first stent was inserted uneventfully into the proximal LAD artery, after which an attempt was made to insert the second stent into the mid-portion of the LAD artery because of the irregularity

of the lesion. However, when the stent was extracted from the balloon, it was trapped and deformed. One part of it floated in the left coronary sinus (Fig. 1). We tried to push and withdraw the stent by snaring it, but failed. We planned the surgical removal of the trapped stent and a coronary ar- tery bypass graft. With cardiopulmonary bypass, we were able to remove the stent through the aortotomy site (Fig. 2). We also performed left internal thoracic artery bypass to the dis- tal portion of the LAD artery. The next day, the patient was extubated and he recovered well. However, on the second postoperative day, he had a sudden cough that produced fresh blood. He was intubated again and was subjected to chest computed tomography (CT). The chest CT showed active bleeding from the right middle lobe (Fig. 3). A lesion was al- so found in the bronchoscopy examination. We resectioned the right middle lobe. The lesion in the right middle lobe may have existed before the coronary angiography. In the fol- low-up echocardiography, the wall motion of the left ventricle was good. The ejection fraction increased from 35% to 65%.

The patient had postoperative pneumonia and acute renal failure.

Korean J Thorac Cardiovasc Surg 2015;48:368-370 □ Case Report □

http://dx.doi.org/10.5090/kjtcs.2015.48.5.368

Trapped Stent in Myocardial Infarction Patient

− 369 − Fig. 1. First stent deployed successfully in the proximal portion of the left anterior descending artery (dotted arrow). The second stent was entrapped and floated in the left coronary sinus (solid arrow).

Fig. 2. (A) Entrapped and deformed stent in the left coronary sinus (circle).

(B) Deformed stent after its bailout.

He was treated with active intensive care including antibio- tics, hemodialysis, and pulmonary rehabilitation. His condition waxed and waned. He was improving and underwent con- servative treatment including hemodialysis in the general ward.

However, unfortunately, he passed away at 5 months after the operation due to aspiration pneumonia.

DISCUSSION

Entrapment of a coronary stent is a rare and dangerous complication of percutaneous coronary intervention. It may be life-threatening and may sometimes require emergency surgi-

cal treatment. The increased use of endovascular intervention has resulted in an increasing number of complications pertain- ing to unretrievable devices due to abrupt entrapment. Several bailout devices have been developed such as GooseNeck snares, basket retrieval devices, and angioplasty balloons. In a previous study, 15% to 20% of the cases of failed percuta- neous retrieval of catheter remnants were referred for surgical removal [1].

An angulated coronary anatomy, coronary calcification, a long stent, and sequential stents may cause stent entrapment [2]. In the case of a long lesion, the distal stent is generally inserted earlier, because if the proximal stent is inserted ear- lier, it may entrap the distal stent. In addition, poor stent tractability, flexibility, and conformability may cause stent en- trapment in the coronary artery. In one case, the order of in- sertion of sequential stents in a long coronary lesion was in- verted, but the patient had no other predisposing factors.

These days, to improve flexibility, stents often have fewer fixed links than the past stents. However, these designs might reduce the strength of the stent and, therefore, pose an in- creased risk of longitudinal deformation, which is a cause of stent entrapment [3].

An entrapped stent could cause a blood clot. This may be

critical because it may cause sudden myocardial infarction

[4]. Transcatheter removal of an entrapped stent is usually

better, faster, and safer than surgical removal. The use of a

snaring wire or another balloon is a treatment alternative for

stent entrapment. However, if this does not work, surgical

treatment should be strongly considered, particularly in the

Sun Han and Pil Won Seo

− 370 − Fig. 3. Chest computed tomography showing active bleeding from the right middle lobe (arrow).

left coronary opening, as in our patient. However, surgical in- tervention may have catastrophic results. With respect to a coronary artery bypass graft, it is preferable to anastomose the graft to the coronary segment distal to the entrapment site. In conclusion, here, we have reported a case of stent en- trapment, which is a rare complication of percutaneous coro-

nary intervention.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

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