We report an elective angioplasty of a left circumflex artery (LCx) bifurcation lesion treated by provisional stenting. With a “jailed” wire in the first obtuse marginal, we deployed a 3.0 x 28 mm drug-eluting stent into the main branch. The jailed wire was tangled up in a tortuous side branch. We were unable to retrieve the wire. Forceful wire removal led to an unintended extraction of the fully deployed stent from the main branch. J INVASIVE CARDIOL 2007;19:496–499 Key Words: coronary artery disease; angioplasty; stents; bifurcation

       Provisional stenting is the most widely used method for the treatment of bifurcation coronary artery lesions. It consists of the placement of the first stent in the main branch, followed by provisional stenting of the side branch through the main branch stent. The advantage of this approach is its simplicity and predictable results. Generally, a stent is placed in the main branch and the use of a second stent (in the side branch) is based on the angiographic appearance.
       The “jailed” wire technique maintains side branch patency and facilitates side branch access through the main branch stent struts secondary to angle modification. Though retrieval of the “jailed” wire should be performed with caution because of the risk of proximal coronary artery dissection by the guiding catheter, it is generally considered a safe maneuver.^1,2

       Case Report. A 74-year-old male with a history of insulindependent diabetes mellitus and hypercholesterolemia was treated for myocardial infarction with direct angioplasty of the right coronary artery (RCA) in March 2006. During this procedure, a complex lesion of the left circumflex (LCx) artery was documented, and elective staged coronary intervention was scheduled 1 month later to treat the patient’s angina pectoris (Canadian Cardiovascular Society, Class III) (Figure 1).

Figure 2.

Guidewire insertion in the distal part of the left circumflex (LCx). In the obtuse marginal, it was only possible to insert the soft part of the guidewire through the tortuous mid-portion of the vessel.

Figure 1.

Left circumflex (LCx) artery angiogram showing a bifurcation lesion in the proximal segment of the LCx and the tortuous first obtuse marginal, and a focal lesion in the distal LCx.

       The patient was pretreated with 100 mg of aspirin and 600 mg of clopidogrel. After insertion of a 6 Fr sheath into the right radial artery, 100 IU/kg per of unfractionated heparin were administered. An activating clotting time of 292 seconds was achieved. The ostium of the LCx was cannulated with a 6 Fr Vista XB Brite Tip 3.5 guiding catheter (Cordis Corp., Miami Lakes, Florida), and a 0.014 inch Stabilizer^® guidewire (Cordis) was used to crossthe bifurcation lesion in the distal segment of the LCx. Placement of an IQ™ guidewire (Boston Scientific Corp., Natick, Massachusetts) in the obtuse marginal (Figure 2) then followed.

       The main branch was predilated with 3.0 x 20 mm Maverick^® balloon catheter (Boston Scientific), then a paclitaxeleluting 3.0 x 28 mm Taxus^® stent (Boston Scientific) was implanted at 12 atm (Figure 3). The distal lesion of the LCx was then treated with direct stenting utilizing a 3.0 x 9 mm F1 stent (Jomed, Helsingborg, Sweden), which was deployed at 18 atm (Figure 4). This balloon was then used for postdilatation of the Taxus stent to 18 atm. Subsequent angiography to document optimal stent expansion was performed. We pulled the guidewire back into the Taxus stent and tried to cross through the struts into the obtuse marginal branch. Because of the shortened, angulated proximal LCx and the acute angle between the LCx and obtuse marginal branch, we were unable to pass the wire into the ostium of the obtuse marginal. This led to distortion and twisting of the jailed wire in the mid-portion of the obtuse marginal branch.

Figure 4.

Focal direct stenting with a 3.0 x 9 mm F1 stent at 18 atm in the distal circumflex artery.

Figure 3.

Deployment of a 3.0 x 28 mm Taxus® stent at 12 atm in the proximal segment of the circumflex artery.

       After 15 minutes of the fluoroscopy time, we decided to abort any further effort to enter the side branch. Removal of the Stabilizer wire from the main branch was accomplished without difficulty, but there was a marked resistance while retrieving the wire back from the side branch. At this time, we could not identify the reason for unusual resistance while removing the jailed wire.
       At this time, the patient began to complain of chest pain, and the decision was made to remove the guiding catheter and the guidewire as a whole. After guiding catheter and guidewire extraction, theTaxus stent was present at the end of the guidewire. The stent was markedly distorted and was captured by a tangle on the IQ guidewire (Figures 5 and 6). Due to continuous chest pain, we cannulated the left coronary artery again with a 6 Fr Vista XB Brite Tip 3.5 guiding catheter (Cordis). The LCx was widely patent, but the obtuse marginal branch was occluded in its midportion (Figure 7). We started eptifibatide administration with 2 boluses of 180 μg/kg (Integrilin , GlaxoSmithKline, United Kingdom) for a 5-minute period, as well as continuous intravenous infusion of 2 μg/ kg/ minute. The proximal part of the LCx artery was carefully crossed with an IQ guidewire (Boston Scientific) to avoid possible dissection induced by removal of a distorted Taxus stent.

Figure 6.

Tight kink of the guidewire on the stent strut.

Figure 5.

Distorted 3.0 x 28 mm Taxus® stent after unintended extraction from coronary artery.

       A 3.0 x 30 mm Driver^® stent (Medtronic Inc., Minneapolis, Minnesota) was advanced into the proximal part of the LCx in the previous position of the Taxus stent and deployed at 12 atm. The final LCx result was optimal with TIMI 3 flow and no residual stenosis, but the obtuse marginal was left with significant ostial stenosis and TIMI 1 flow (Figure 8).
       The patient’s postprocedure course was uneventful. An elevation of troponin I to 19 μmol/l (upper range of normal 1.0 μmol/l), and a rise in CK-MB values to 1.11 μmol/l (upper range of normal 0.42 μmol/l) were observed. The patient was discharged the third day after the procedure on aspirin 100 mg/day indefinitely and clopidogrel 75 mg for 6 months. The patient had an uneventful 7-month follow up without recurrence of angina pectoris.

Figure 8.

Final result showing a 3.0 x 30 mm Driver stent in the proximal left circumflex artery and ostial stenosis on the first obtuse marginal with difficult contrast penetration through the middle part of the vessel.

Figure 7.

Situation after stent extraction. Small dissection on the left circumflex between first and second obtuse marginal. First obtuse marginal is closed in the middle part.

       Discussion. Treatment of bifurcation lesions with the provisional stenting approach is associated with a high angiographic success rate in both branches (≥ 98%) and a low rate of in-hospital major adverse cardiac events.^1,2 Final kissing-balloon dilatation is necessary for correction of stent deformation induced by opening the struts into a side branch. The exchange of wires (jailed wire from the side branch and guidewire from the main branch) is the pivotal step that leads to achieving an optimal result. The exchange procedure is usually simple. However, the operator is mainly concerned with preventing the intubation of the guiding catheter too deeply while pulling back the jailed guidewire. Substantive resistance is rare and is generally caused by deploying a long stent segment proximal to the branch vessel. Factors leading to greater resistance with jailed wire retraction include heavy calcification of the target vessel, vessel tortuosity and high-pressure dilatation of the stent before wire exchange.
       There have been reports of stent extraction following the use of bulky devices, particularly following the use of a cutting balloon, directional coronaryatherectomy, intravascular ultrasound or distal protection devices.^3–9 Despite high-pressure deployment, surgical stent removal in certain cases may be unavoidable, such as in endarterectomy procedures to remove tubular stents many years after their initial implantation.^10–12 Catheter techniques permit extraction of embolized, nondeployed stents as well as fully deployed coil stents without coronary artery damage.^13,14 Surgery is usually indicated for entrapment of less bulky devices, such as guidewires or balloons, or for complications of entrapment (device fracture, significant myocardial ischemia caused by an entrapped device). The outcome of surgical procedures depends on specific, individual situations.^10,15–17
       In the case described here, we could not identify any clear reason for difficult pullback of the jailed guidewire. Because of the development of chest pain, coronary artery spasm of the tortuous obtuse marginal was suspected as the cause of myocardial ischemia, and guidewire removal was considered necessary to ameliorate the patient’s symptoms. After guidewire and stent extraction, a tight kink on the guidewire captured between the stent struts was identified as a possible reason for the strong resistance. Pullback of the kinked guidewire may have led to coronary artery spasm or a small dissection in the mid-portion of the obtuse marginal branch, leading to myocardial ischemia in the vessel territory. Taking into account the large territory of the LCx and the traumatic nature of the stent extraction, we opted first to cover the region of the extracted Taxus stent.
       The take-home message of this case suggests that when performing provisional stenting, it is important to check the position of the jailed guidewire in a tortuous side branch, as it may be necessary in order to achieve favorable results. Due to its mechanical properties, the guidewire may have been resistant to rupture, resulting in distortion of the extracted stent. Despite the traumatic extraction, injury to the coronary artery was limited to a small dissection below the bifurcation.