Case 134: Manual of PCI - Stent loss

A patient with multivessel coronary artery disease (severe stenosis in the proximal/mid LAD and the proximal circumflex with severe calcification) was referred for CABG but declined and was referred for complex PCI. The circumflex was treated first. Balloon delivery was successful but the balloon ruptured. Orbital atherectomy was performed, followed by balloon angioplasty and successful stenting. A balloon could not be delivered to the LAD due to the severity of the LAD stenosis and severe calcification. After orbital atherectomy a 3.0x40 mm DES was deployed from the LAD ostium to the mid LAD. The stent expanded well but there remained disease distally. We attempted to deliver a 2.75x18 mm DES to the mid LAD, but the stent came off the balloon in the proximal LAD. We tried to retrieve the stent using the small balloon technique without success. We deployed the lost stent inside the previously deployed proximal LAD stent and used a guide extension to deliver another DES to the mid LAD with a nice result. The proximal circumflex appeared suboptimal, hence stenting was performed from the circumflex into the left main using the provisional technique. After POT, the LAD was rewired followed by kissing balloon inflation and final POT with an excellent final result as confirmed by IVUS. The patient had an uneventful recovery.

[@shangz0216]

Thanks for the educative case sharing.

[@ivancarel2834]

Maybe consider using guiding extension on first hand to deliver the 2’.75 mm in LAD
Doing this « larga manu » in this kind of situation (recrossing long stent /calcification etc..) allowed us to loose very few stents this past years
Thanks for your always very interesting cases !
Dr Ivan Carel /France

[@Clapro01]

Thanks for the great educational case!
I'm a bit twitchy about the LMS bifurcation stenting technique used. I appreciate decisions were made step by step, but we have no clue where the LAD stent landed proximally and there's a good chance distal LMS into ostial LAD was not covered by the stent. Was final IVUS LAD-LMS performed? Do you think different bifurcation strategies could have been used in the end? Many thanks!!

[@ramsesthabet5589]

A lot of operators are hesitant to perform atherectomy after predilation for fear of presence of dissection and resultant perforation… what’s your opinion? and is there a certain atm beyond which atherectomy should be performed, some say below 4-6 atm it’s ok but if higher should wait 3-4 weeks and bring back for atherectomy… what’s your opinion Dr Brilakis please ?

[@manosbrilakis]

Atherectomy can be performed ater predilation, even if there is an angiographic dissection (provided that there is a resons for atherectomy, such as balloon undilatable lesion). Would carefully monitor the ECG during atherectomy runs. The risk of deferring PCI for later is acute vessel closure.