Coronary stent loss and its migration is one of complications of percutaneous coronary interventions
(PCI). We present a case of successful retrieval of a coronary stent which moved
initially to the left renal artery. Subsequently the stent was lost again and migrated to the left
deep femoral artery, while an attempt was made at its retrieval with a snare loop from the renal
artery. Successful retrieval was finally performed through right femoral access by the so-called
&#8220;cross-over&#8221; method. (Cardiol J 2007; 14: 87&#8211;90

Bychowiec, Bartosz

Dziarmaga, Mieczysław

Juszkat, Robert

Żabicki, Bartosz

English

Via Medica Journals

87www.cardiologyjournal.orgCASE REPORTCardiology Journal2007, Vol. 14, No. 1, pp. 87–90Copyright © 2007 Via MedicaISSN 1507–4145Address for correspondence: Bartosz ŻabickiDepartment of RadiologyPoznań University of Medical SciencesDługa 1/2 61–848 Poznań, PolandTel: +48 61 8549 270, fax: +48 61 854 90 83e-mail: bzabicki@tlen.plReceived: 11.08.2006 Accepted: 23.11.2006Successful coronary stent retrievalfrom the renal arteryRobert Juszkat1, Mieczysław Dziarmaga2, Bartosz Żabicki1 and Bartosz Bychowiec21Department of Radiology, Poznań University of Medical Sciences, Poznań, Poland2Interventional Cardiology Unit, Department of Cardiology,Poznań University of Medical Sciences, Poznań, PolandAbstractCoronary stent loss and its migration is one of complications of percutaneous coronary inter-ventions (PCI). We present a case of successful retrieval of a coronary stent which movedinitially to the left renal artery. Subsequently the stent was lost again and migrated to the leftdeep femoral artery, while an attempt was made at its retrieval with a snare loop from the renalartery. Successful retrieval was finally performed through right femoral access by the so-called“cross-over” method. (Cardiol J 2007; 14: 87–90)Key words: complication, percutaneous coronary intervention, stent loss,retrieval, snare loopIntroductionStent loss is a rare complication of percutane-ous coronary intervention (PCI) [1, 2]. Although thenumber of PCI procedures has significantly in-creased over the years, the incidence of stent losshas decreased and remains at a rate of 0.2% [1]. Thefall in the rate of this complication is due to thegreater experience of interventional cardiologistsand improvements in equipment, especially in thecommon use of premounted stents [1, 3].Stent loss is more likely to occur in lesionswhich are significantly angulated proximally to thelesion and when calcification is present [1, 4]. Stentmigration, when it does occur, may lead to severecomplications, depending on its destination vessel.It may embolise in the coronary circulation andevoke cardiac infarction, which is an indication toemergency coronary artery bypass grafting(CABG). Alternatively, it may cause embolic cere-brovascular events, peripheral in-stent embolisa-tion, bleeding or even death [1, 3, 5].There are many methods of stent retrieval. Thefollowing devices can be used: a small-balloon cath-eter, a snare loop, the two-wire technique and in-struments used only beyond the coronary circula-tion such as grasping forceps and basket retrievaldevices [1, 6–11]. The snare loop currently appearsto be the most efficient retrieval device [2, 12].If stent retrieval is not possible, an attempt can alwaysbe made to crush it against the vascular wall with an-other stent so as to stabilise the first one [1, 6].In our case the snare loop was the right tool forsuccessful retrieval of a stent from the renal arteryand subsequently from the deep femoral artery.The authors of this case report have not foundany previously published cases describing loss andmigration of a stent to the renal artery during PCI.Case historyA 63-year-old woman was admitted to our unitbecause of unstable angina. The first symptoms hadoccurred 7 days prior to hospitalisation but there88Cardiology Journal 2007, Vol. 14, No. 1www.cardiologyjournal.orgwas no chest pain at the moment of admission tothe hospital.Resting ECG showed small R-wave progres-sion in V1–V3 and T-inversion in lead III, but therewas no increase in cardiac enzymes (troponin T, CK).Echocardiography was normal with an ejection frac-tion of 64%. The patient presented with the twinrisk factors for coronary artery disease of hyperc-holesterolaemia and hypertension. An additionallaboratory test revealed type 2 diabetes. Diagnos-tic coronary angiography performed by femoral ap-proach showed significant stenosis (90%) in theright coronary artery (RCA). There was no otherstenosis in the coronary artery tree.The patient was referred for PCI. The targetlesion was predilated with a Powersail balloon (3.5//18 mm) inflated at 10 atms. A drug-eluting stent,Taxus Liberte (3.5/20 mm), was delivered to the RCA.During the implantation the stent wedged and wasthen released to the aorta. Fluoroscopy excluded thepossibility of dislocation of the stent to the arteries ofthe central nervous system and so the procedure wascontinued. After redilatation of the stenosis spiral dis-section and artery occlusion occurred. The lesion wascovered by two bare metal stents (Liberte 3.5/24 mmand 3.5/20 mm) inflated at 12–18 atms.  The implant-ed stents were postdilated with a Powersail balloon4.0/18 mm (12 atms) with a very good angiographicresult (TIMI 3). ReoPro was administered. There wasno periprocedural troponin T increase.The next day, on the basis of fluoroscopy anddigital subtractive angiography (DSA), the dislocatedstent was localised in the bifurcation of the left renalartery (Fig. 1). Digital subtractive angiography of theabdominal aorta and renal artery was performed byfemoral approach with the use of a “pigtail” Baltoncatheter (5 F) placed in the aorta up to L1/L2. Next,selective catheterisation of the left renal artery wascarried out by means of a femoral-renal catheter(5 F, Balton). Digital subtractive angiography wasperformed in three different projections in order tolocalise the stent precisely and to determine themost efficient removal strategy. The stent was lo-calised in the bifurcation of the renal artery in thelong axis parallel to the vessel lumen. The larger partof the stent was distal to the point of bifurcation.The evacuation of the stent was performed bysnare loop Lasso 0.009 (Balt, Montmorency,France). Because of the difficulties caused by theperipheral position of the stent, the Lasso loop wasanchored in its proximal part. The evacuation fromthe left renal artery was successful, although theLasso loop slackened and another dislocation tookplace (Fig. 2). This time the stent moved to the deepFigure 1. Digital subtractive angiography. Selective ca-theterisation of the left renal artery was performed. Thestent is not deployed and is located in the dorsal branchof the renal artery beyond its bifurcation.Figure 2. Stent retrieved with a snare loop.89Robert Juszkat et al., Successful coronary stent retrieval from the renal arterywww.cardiologyjournal.orgfemoral artery (Fig. 3). After exact location of thestent it was removed with the use of a catheter withtwo guide wires (Fig. 4). The procedure was per-formed through the right femoral access by the so-called “cross-over” technique.The common iliac artery was cannulated withthe use of a 5 F Sidewinder catheter (Balton, Poland)and hydrophilic wire 0.035 (Terumo, Japan). A 5FBalton straight catheter was then advanced over thewire into the deep femoral artery next to the loststent. Successful retrieval of the coronary stent wasfinally performed by the two-wire technique. TheGuidant Hi torque floppy wires 0.014’, of length 300cm, (Advanced Cardiovascular System Inc. CA, USA)were arranged into a basket retrieval device. No com-plications occurred during the procedure.Diagnostic DSA of the renal arteries, abdomi-nal aorta and the arteries of the lower limbs showedno iatrogenic damage to the vessels investigated.The patient was discharged on the third day in verygood condition.DiscussionAs a result of the increasing experience ofteams performing PCIs and the universal use ofpremounted stents, stent loss and its migrationdoes not occur very often. However, anatomicalcircumstances, such as arterial tortuosity in thelocation proximal to the lesion and significant cal-cification of the lesion, increase the frequency ofthis complication [1, 13]. Stent loss is most likelyto occur during the withdrawal of a balloon cathe-ter with a stent to the guiding catheter, if the le-sion could not be reached or if the stenosis couldnot be passed with the stent and balloon catheter[3, 5]. Furthermore, inadequate control of a therapeu-tic catheter with a guiding catheter or the guidingcatheter falling out as a result of its shallow intro-duction to the coronary artery increase the risk rateof slip-off and loss of the stent. It is also reportedthat direct stenting without predilatation or intro-duction of one stent through the other stent are alsorisk factors for incorrect stenting and misplacementof the stent [5, 13]. No correlation is found betweenthe complication rate and the location of the lesionin the right (RCA) or left coronary artery (LCA) orits precise location along the vessel [1, 3].A case of stent migration to the renal artery hasnever before been published, and therefore it is hardto determine with confidence how serious the com-plications could be, if stent retrieval were aban-doned, or if the retrieval were ineffective and onlyanticoagulants administered. It is known that stentembolisation during PCI mostly occurs within thecoronary arteries. Hence in-stent coagulation anda high risk of cardiac infarction is definitely an indi-cation to attempt stent retrieval. Similarly the cor-onary stent may migrate in the cerebral direction,where it could be a potential cause of ischaemicapoplexy and neurological deficiency symptoms.Peripheral stent embolisation is fairly safe. Stentwithdrawal under the left subclavian artery levelalso seems to be free from further serious compli-cations [13]. There are no clinical symptoms in mostcases of peripheral embolisation, although intermit-tent claudication or acute ischaemia of the lowerextremity may occur [4, 13]. In our case we attempt-ed to retrieve the lost stent from the renal arteryto avoid diminished renal perfusion, total embolisationFigure 4. Stent retrieved with the two-wire technique.Figure 3. Stent located in the bifurcation of the deepfemoral artery.90Cardiology Journal 2007, Vol. 14, No. 1www.cardiologyjournal.orgof the left renal artery trunk or possible damage tothe vessel by a balloting stent and bleeding.Of all the instruments in the introduction thesnare loop is often the device of first choice (Gabel-mann et al.: 77.7%) [6]. This intravascular deviceis relatively safe and easy to use. It has a low rateof complications and appears to be very effective[10, 12]. However, the choice of retrieval techniqueshould be specific to each case and to the operator’sexperience. The decision must be taken in the lightof the location of a stent, the type of stent and itsdeployment status. A snare loop appeared to be thebest method of retrieval in our case, because ourlost stent had not been deployed and did not rideon a guide wire. The use of low-profile balloon cath-eters is also very effective, especially in caseswhere a stent is still riding on a guide wire and isdeployed enough to advance a small-balloon cathe-ter through its lumen. The latter method was oftenchosen by Brilakis and Eggebrecht with a successrate of 50–70%. In comparison Brilakis succeededwith a snare loop in 100% and Eggebrecht in 25%only [1, 3]. The use of other devices such as thegrasping forceps may be equally effective, but thiscan only be used outside coronary arteries and islinked with a higher risk of vessel damage.In our case the snare loop loosened duringwithdrawal of the stent from the renal artery to theabdominal aorta. The stent was lost and migratedwith the blood stream to the left deep femoral ar-tery and was finally extracted using two 0.014 in-termingling guide wires guided in one catheter. Theattempt at further stent extraction from this arterycould probably have been abandoned and conserv-ative treatment applied. If in-stent embolisation ofthe deep femoral artery occurs, there are no symp-toms or only insignificant symptoms of ischaemia.Yet there seemed to be no contraindications for anexperienced team to attempt to perform a success-ful stent retrieval to minimise the possibility of anysymptoms of ischemia.If there is no way to retrieve a stent, it is al-ways possible to try to reimplant it in a safer loca-tion or to stabilise it using another stent. Nowadays,with the dynamic development of intravascular pro-cedures, stent loss occurs very rarely. Neverthe-less every catheterisation laboratory should beequipped with a set of instruments for intravascu-lar foreign body retrieval and interventional cardi-ologists or radiologists should be familiar with theseretrieval techniques.References1. Brilakis ES, Best PJM, Elesber AA et al. Incidence,retrieval methods, and outcomes of stent loss duringPercutaneus Coronary Intervention: A large single-center experience. Catheter Cardiovasc Interv, 2005;65: 333–340.2. Patel TM, Shah SC, Gupta AK, Ranjan A. Successfulretrieval of transradially delivered unexpanded coro-nary stent from the left main coronary Artery. IndianHeart J, 2002; 54: 715–716.3. Eggebrecht H, Haude M, von Birgelen C et al. Non--surgical retrieval of embolized coronary stents.Catheter Cardiovasc Interv, 2000; 51: 432–440.4. Roffi M, Luscher TF, Sutsch G et al. Failure to re-trieve undeployed paclitaxel-eluting coronary stents.Am J Cardiol, 2006; 97: 502–505.5. Chu CS, Lee ST, Lee KT et al. Successful retrievalof dislodged paclitaxel-eluting stent with a nitinolloop snare: A case report. Kaohsiung J Med Sci,2005; 21: 566–570.6. Gabelmann A, Kramer S, Gorich J. Percutaneus re-trieval of lost or misplaced intravascular objects. AmJ Roentgenol, 2001; 176: 1509–1513.7. Kim MH, Cha KS, Kim JS. Retrieval of dislodged anddisfigured transradially delivered coronary stent: re-port on a case using forceps and antegrade brachialsheath insertion. Catheter Cardiovasc Interv, 2001;52: 489–491.8. Rozenman Y, Burstein M, Hasin Y, Gotsman MS.Retrieval of occluding unexpanded Palmaz-Schatzstent from a saphenous aorto-coronary vein graft.Cathet Cardiovasc Diagn, 1995; 34: 159–161.9. Antonellis IP, Patsilnakos SP, Pamboukas CA et al.Successful withdrawal from the right coronary ar-tery of an NIR stent dislodged from the balloon cath-eter. J Interv Cardiol, 1999; 3: 215–218.10. Seong CK, Kim YJ, Chung JW et al. Tubular foreignbody or stent: safe retrieval or repositioning using thecoaxial snare technique. Korean J Radiol, 2002; 3: 30–37.11. Madronero JL, Hein F, Bergbauer M. Removal ofa ruptured, detached, and entrapped angioplasty bal-loon after coronary stenting. J Invasive Cardiol, 2000;12: 102–104.12. Koseoglu K, Parildar M, Oran I, Memis A. Retrievalof intravascular foreign bodies with goose necksnare. Eur J Radiol, 2004; 49: 281–285.13. Drozd J, Zapolski T, Wójcik J. Usunięcie stentuz lewej komory serca po nieudanej implantacji dogałęzi międzykomorowej przedniej lewej tętnicywieńcowej. Kardiol Pol, 2005, 62: 250–253.

Successful coronary stent retrieval from the renal artery

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Successful coronary stent retrieval from the renal artery

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