27.

1
How to approach stent
loss

Emmanouil S. Brilakis, MD, PhD

 Acute Complications of PCI

Cardiac
Non-cardiac
Coronary Non-coronary

1. Hypotension 1. Vascular access

Acute vessel closure
2. Myocardial infarction complications
1. Dissection
3. Arrhythmias 2. Thromboembolic
• Coronary
Perforation 4. Tamponade complications
• Aortocoronary
• main vessel 3. Contrast-related
2. Thrombosis • distal vessel complications
3. Embolization • collateral (nephropathy, allergies)
• Thrombus
4. Radiation injury
• Plaque
• Air
4. Side branch occlusion
5. Spasm Equipment
6. Pseudolesion loss/entrapment
7. Equipment entrapment
8. Intramural hematoma
9. Aortic dissection
 CAUSES
PREVENTION
 Stent loss
Causes
1. Tortuosity + calcification
2. Poor vessel prep – direct
stenting
3. Stent delivery through another
stent
4. Small (5 Fr) guides
5. Forceful stent withdrawal
6. Use of guide extensions
7. Retrograde delivery through
collateral
Mechanisms of stent loss

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

 Stent loss in a
septal perforator

Utsunomiya et. JIC 2009

Unable to advance stent through
Guideliner….
 Stent loss
Prevention
1. Avoid direct stenting!
2. Meticulous vessel prep + imaging
3. Stent from distal to proximal
4. Guide extension for challenging delivery
5. Avoid very forceful pushing
6. Push rod of guide extension under towel
7. If resistance felt while withdrawing stent
into guide, STOP!
8. Avoid small (5 Fr) guides
9. Inspect stents that did not deliver before
reinsertion
TREATMENT
 Stent Loss
Treatment

Do not
Retrieve
retrieve
•Deploy
•Crush

“Attempts at removal may make

things worse”
“Retrieval approaches require
imagination, creativity, flexibility and
excellent visualization” David R. Holmes, Jr, MD
 Stent deployment/crushing

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

Left coronary
angiography
IVUS post 3.5x18 mm Unable to cross mid circ lesion
DES with 3.5x23 mm DES
 After several attempts to
cross…
TIMI 0 flow – ST elevation
Stent stripped off balloon…

A. Call surgeons

B. Snare stent

C. Deploy stent

D. Insert IABP
and admit to
CCU
 3.0x15 mm balloon
Next step?

A. Call surgeons

B. Snare stent

C. Deploy stent

D. Insert IABP
and admit to
CCU
One of the stents that came out…
3.0x12 mm DES implanted
– flow restored, but
attempt to cover proximal
dissection – 3.5x18 mm
DES lost again in left main
– deployed with 3.5 mm
balloon…
Wire exchange Proxis

Transit

Ironman
3.0 x 12 mm DES 3.5x12 mm DES
Final Result
Stent retrieval: small balloon technique

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

Proximal cap: Tapered stump

Length: 30 mm

Distal vessel: Good quality

Large non-tortuous
Collaterals:
epicardial

Plan
• Antegrade wiring
• Retrograde via epicardial
• ADR
CTOmanual.org – case 128
 Stent came off the balloon
22.5 x 32 mm DES
CTOmanual.org – case 128
 1.5 x 15 mm balloon

1.5x15 mm balloon Stent retrieval

CTOmanual.org – case 128
CTOmanual.org – case 128
CTOmanual.org – case 128
1.5 x 15 mm balloon

CTOmanual.org – case 128

 Multiple
RCA lesions

PCImanual.org – case 10
PCImanual.org – case 10
 Distal wiring and
predilation with 2.5/3.0
balloons

PCImanual.org – case 10
Unable to deliver stent – resistance
while removing – balloon came out
but stent did not…

Now what?
PCImanual.org – case 10
2.5 x 12 mm balloon inflation in GC for stent withdrawal

PCImanual.org – case 10
Successful stent retrieval

PCImanual.org – case 10
 Stent retrieval: loop snare

Brilakis, Garratt. Strategic Approach to coronary interventions 2005

 18.5 Snares
* Use through
coronary guide

Ensnare - Atrieve Amplatz Goose neck

18-30 mm
27-45 mm
Courtesy: Dr. Kambis Mashayekhi
Amplatz Goose Neck Microsnare
Goose neck snare: how does it
work?
Goose neck snare: how does it
work?
 Microsnares

Mini snare (3.2 French)

Loop diameter:
2-4 mm
Loop diameter: 4-8 mm
2 mm
4 mm
7 mm
LAD
Xience 2.5x23:
balloon came
out but stent in
left main…
Microsnare Elite
IVUS
En snare
Retrieved stent
IVUS post
LAD stenting
Guidewire twirling technique