Successful management of guide extension catheter entrapment by stent in severe calcified lesion

Excerpt

A 74-year-old Japanese man with 7-year hemodialysis history was admitted for acute coronary syndrome. The coronary angiogram and intravascular ultrasound revealed significant stenosis with severe calcification at the middle part of the right coronary artery (Fig. 1A). The 4.0-mm everolimus-eluting stent (SYNERGY^®; Boston Scientific, Marlborough, MA, USA) could not pass despite full dilatation with 3.0-mm cutting balloon and 4.0-mm non-compliant balloon. Ultimately, it was passed using the guide extension catheter (GEC) (GUIDEPLUS^®; Nipro, Osaka, Japan). As the GEC was less visible on angiogram because of severe coronary calcification, it advanced when the stent was pulled back to its intended position and entrapped by almost the whole implanted stent (Fig. 1B, C). We attempted to pull the GEC by deeply engaging the guiding catheter. However, retrieving the GEC alone was difficult, and the shaft detached from the distal tube at the connection. Therefore, we tried to pull the stent balloon while expanding at low pressure and anchoring the GEC and stent. Consequently, stent and GEC were successfully removed integrally using stent elongation (Fig. 1D, E), and new stent was implanted (Fig. 1F). GUIDEPLUS^® has good trackability, although the tip is less visible, and can advance during stent alignment. There are several reports of GEC entrapment by implanted stent’s proximal part [1, 2]. Here, the GEC was entrapped by almost the whole implanted stent, and retrieving it alone was difficult due to its friction with the under-expanded stent. We could remove them together because stent elongation during pulling the stent balloon reduced friction with vessel wall. If GEC removal is difficult using this method, we present an alternative: grasp the entrapped GEC using a snare catheter and pull it out or surgically extirpate. The GEC shaft may cause metal fatigue while inserted in a calcified lesion, therefore, operators should be careful when removing it. Pulling the stent balloon may cause the balloon and GEC shaft detachment; however, it can be considered a bailout technique in the first step for the GEC entrapment by almost the whole implanted stent.

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