We describe a case report of coronary stent avulsion by a jailed side-branch pressure wire. Diagnosis was confirmed by angiographic and intravascular ultrasound imaging. The avulsed stent was treated by crushing to the vessel wall by a second stent.

Provisional stenting is advocated as the default bifurcation stenting technique which jails a side-branch wire. The jailed wire keeps side-branch open and increases success of intervention if it occludes [1]. However, complications like jailed wire fracture/unravelling, stent avulsion or vessel injury during jailed wire retrieval may occur. Stent avulsion is a rare complication of percutaneous coronary intervention (PCI) where stent segment is displaced from original implantation site due to interaction with intracoronary devices like guidewires or balloon catheters while the intact stent segment remained in the intended area. The avulsed stent becomes stretched and deformed [2]. There is no consensus for managing this complication. We describe a case report of coronary stent avulsion during retrieval of an entrapped side-branch pressure wire

A 60-year-old male with angina underwent coronary angiogram which showed proximal to mid LAD diffuse disease (Figures 1 and 2). EBU 3.0 6Fr guiding catheter was used for LAD fractional flow reserve (FFR) measurement using Pressure Wire X (Abbott, IL, USA). FFR was 0.75. Stenting of proximal to mid LAD was decided. LAD was wired with Sion Blue to provide support to deliver a long stent and pressure wire was repositioned to D2 (Figure 3). After predilatation, CRE8 Evo 2.75 x 46 mm stent (Alvimedica, Turkey) was positioned in LAD using its radiopaque markers. Stent was deployed (Figure 4) and postdilated with non-compliant 3.0 x 15 mm balloon. Satisfactory result was achieved with proximal stent marker in proximal LAD (Figure 5 and 6). Resistance was felt when removing the jailed pressure wire. Pressure wire was successfully removed with disengagement of guiding catheter and forcefully pulling on the wire. Angiogram showed hazy defect in proximal LAD (Figure 7). Proximal stent marker was displaced to the left coronary cusp (LCC) (Figure 8). LAD was rewired and dilated with 3.0 x15 mm balloon. Intravascular ultrasound (IVUS) confirmed stent integrity beyond D2. Stent was deformed proximal to D2. It elongated through left main artery (LM) and protruded into LCC. There was incomplete stent apposition and plaque protrusion in proximal LAD (Figure 9). Examination of pressure wire showed no missing segment. Decision was made to stent and crush the deformed stent from ostial LM to mid LAD leaving a segment of unraveled stent in LCC. This was a safer alternative to an attempted snare retrieval of the stent with high likelihood of vessel injury. Surgery was declined by the patient. To reduce the likelihood of deformation of the second stent by the unraveled stent, a 6F Boosting guider extension catheter was positioned in mid LAD. A CRE8 3.5 x 46 mm stent was deployed from ostial LM to mid LAD beyond D2. The stent was post-dilated with noncompliant 3.5 and 4.0 mm balloons (Figure 10). IVUS showed that the second stent crushed the unraveled stent to the vessel wall (Figure 11). A segment of avulsed stent remained beyond LM in LCC. Patient was pain-free during procedure and was dischargedthe following day. He was prescribed lifelong dual anti-platelet therapy (DAPT). He was reviewed in clinic after 6 months with no angina or hospitalization.

Figure 1: Diffuse LAD stenosis (RAO Cranial). 

Figure 2: Diffuse LAD stenosis (RAO Caudal).

Figure 3: Pressure wire positioned in D2. Ostial D2 stenosis (arrow).

Figure 4: Deployment of stent.

Figure 5:  After stent deployment.

Figure 6: Proximal stent marker.