Material embolization during coronary
angioplasty procedures, although rare, significantly
increases morbidity and mortality. The incidence
of stent dislodgement has been estimated at
approximately 1.2%.[
1] When stent dislodgement
occurs, the primary objective is to employ maneuvers
that minimize harm to the patient and prevent
the stent from embolizing, particularly to the
cerebrovascular system.[
1,
3] Various techniques are
available for retrieving embolized material, and the
choice of technique may depend on the diversity
of equipment in the catheterization laboratory,
the patient's clinical condition, and the operator's
clinical experience.
Factors increasing the risk of stent dislodgement
include coronary tortuosity and calcification,
attempting to advance the stent without adequate
vessel preparation, direct stenting, using a small
guiding catheter (e.g., 5F catheter), advancing a stent
through a previously deployed stent, and continuing
to forcefully retract the stent into the guiding catheter
despite resistance.
In our case, during rewiring, the LAD wire passed
through the struts of the IMA stent. Therefore, the
LAD stent could not be advanced, and during the
retraction of the LAD stent, the IMA stent was
dislodged along with it.
In cases where other treatment methods fail, the
technique of crushing the lost stent against the vessel
wall can be performed using another stent. However,
this technique increases the metal burden and should
be applied with caution.[4] If the wire position on
the stent is lost or the stent cannot be retrieved, this
technique may serve as an alternative.[4,5]
The small balloon technique involves advancing
a small balloon towards the stent when the wire
position is preserved, inflating the balloon distal to
the stent, and withdrawing the lost stent along with
the balloon.[6,7] If the balloon has partially advanced
through the stent, inflating it in the proximal
midsection of the lost stent and withdrawing the
system can be attempted.[4]
A variety of snares are used in both coronary
and peripheral circulation. Snare loops are typically
made of nitinol and are advanced into a microcatheter
to be positioned around the lost material before
being withdrawn into the catheter. The Amplatz
Goose Neck snare (Medtronic, Inc., Minneapolis,
MN, USA) features a single loop and is commonly
used in daily practice.[4] If a snare is not available
in the catheterization laboratory, an exchange wire
of similar length (0.014 inches) and a smaller
diagnostic catheter can be used to retrieve the lost
material by removing and reintroducing the catheter
from the distal end.[8,9]
When intervening in the LAD or circumflex
coronary arteries, it is important to treat the distal
coronary lesion first. Otherwise, stent protrusion will
cause difficulties when stenting is required in the
other vessel, and this may cause stent dislodgement.
Stent dislodgement may also cause coronary flow
restriction, and when the stent is removed, there may be damage to the vascular endothelium. A previous
study indicated that no reflow may occur when
postdilatation is performed; therefore, it may be more
logical to implant the stent to the stenosis area rather
than the balloon.[10,11] It is important to note that each
case of stent dislodgement is unique, and different
techniques or combinations of techniques may need
to be employed.
In conclusion, stent dislodgement is a rare
complication in interventional cardiology, but its
frequency has increased with the growing number
of PCIs. The embolized material can be retrieved
using techniques such as the snare technique,
balloon retrieval with a small balloon, twirling/wire
entrapment technique, and surgical methods. While
there is no gold standard method, a versatile approach
should be attempted. If stent dislodgement occurs
while intervening in more than one coronary artery,
and resistance is encountered when retracting the
dislodged stent with the snare method, it should be
considered that the dislodged stent may be attached
to the ostial segment or to a proximally located stent
implanted for another coronary artery.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, analysis, data,
literature review, writing: M.K., Ç.O.; Desing: Ö.B., M.K.;
Control, critical review: Ö.B.; References, material: Ç.O.,
M.K., Ö.B.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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