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Complete Coronary Stent Removal After Optical Coherence Tomography Performance 8 Months Later for Device Entrapment: A Scary Challenge
Case Report
A 62-year-old man presented with unstable angina 8 months earlier. The patient underwent percutaneous coronary intervention (PCI) of the proximal left anterior descending coronary artery with a 2.75 x 15 mm cobalt-chromium sirolimus-eluting stent (Biotronik AG) (Figures 1A-1C). The patient was discharged uneventfully on aspirin and clopidogrel.
Eight months later, the patient was admitted for non-ST segment elevation myocardial infarction (STEMI). Coronary angiography showed late stent thrombosis at the origin of the first septal branch (Figure 1D), probably due to turbulent flow at the level of the septal and diagonal branches and proximal stent malapposition. Optical coherence tomography (OCT) confirmed the presence of thrombus (Figure 1E) and showed in-stent neoatherosclerosis (Figure 1F). Unfortunately, the guidewire was probably advanced through a proximal malapposed stent strut (Figure 1G). Proximal reference lumen diameter (RLD) was 4 mm and distal RLD was 2.70 mm. When removing the OCT catheter, certain resistance was felt due to device entrapment. Small forward-backward movements were unsuccessful to achieve OCT catheter release. Continuous soft traction on both the OCT catheter and guidewire was performed to achieve removal of the system. When the OCT catheter was retrieved, it was found that the stent implanted 8 months earlier had been completely removed over the OCT catheter (Figure 1H). Angiography showed dissection and thrombus (Figure 1I). PCI was performed with a 2.75 x 26 mm cobalt-chromium zotarolimus-eluting stent (Medtronic) that was implanted at 12 atm with optimal stent expansion and apposition after postdilation and proximal optimization technique with a 4 x 8 mm non-compliant balloon for mismatched lesion (Figures 1J-1L). The patient was discharged uneventfully on aspirin and prasugrel.
This case describes an uncommon and potential life-threatening complication during stent assessment by OCT with entrapment and complete stent removal. Possible mechanisms for OCT-catheter entrapment include malapposed stent struts, catheter deformation, and loss of guidewire position. In this case, the OCT catheter was advanced over the guidewire, which was probably passed through a proximal malapposed stent strut. Some tips to avoid potential complications during OCT performance are ensuring an adequate guidewire position, avoiding deep guide catheter intubation during contrast flushing, and reducing the duration of image acquisition with shorter runs.
Affiliations and Disclosures
From the 1Interventional Cardiology Unit, Department of Cardiology, Hospital del Mar. Barcelona, Spain, Heart Diseases Biomedical Research Group, Hospital del Mar Medical Research Institute-IMIM, Barcelona, Spain; and 2the Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted March 31, 2021.
The authors report that patient consent was provided for publication of the images used herein.
Address for correspondence: Hector Cubero-Gallego, MD, PhD, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain. Email: hektorkubero@hotmail.com