Surgical rescue after left anterior descending catheter entrapment causing cardiogenic shock

Interactive CardioVascular and Thoracic Surgery 24 (2017) 140–142 doi:10.1093/icvts/ivw302 Advance Access publication 13 September 2016 CASE REPORT – ADULT CARDIAC Cite this article as: Ventosa-Fernandez G, Moscoso B, Cartañá R, Pereda D. Surgical rescue after left anterior descending catheter entrapment causing cardiogenic shock. Interact CardioVasc Thorac Surg 2017;24:140–2. Surgical rescue after left anterior descending catheter entrapment causing cardiogenic shock Guillermo Ventosa-Fernandez, Bosco Moscoso, Ramón Cartañá and Daniel Pereda* Department of Cardiovascular Surgery, Hospital Clinic, Barcelona, Spain * Corresponding author. Department of Cardiovascular Surgery, Hospital Clinic, 170 Villarroel Street, 08036 Barcelona, Spain. Tel: +34-93-2275515; fax: +34-93-2275749; e-mail: (D. Pereda). Received 17 April 2016; received in revised form 28 June 2016; accepted 22 July 2016 Abstract Entrapment or device loss during percutaneous coronary intervention is a rare but potentially fatal complication. Percutaneous retrieval is possible but surgery can be required on an emergency basis. We present the case of an entrapped balloon catheter in the left anterior descending coronary artery during an elective percutaneous coronary intervention. The patient developed acute myocardial ischaemia and cardiac arrest. Emergency surgical intervention with device retrieval and distal bypass grafting was life-saving. Keywords: Coronary artery bypass grafting • Cardiac catheterization/intervention • Foreign body INTRODUCTION Hardware loss or entrapment in the coronary arteries is a rare but potentially catastrophic complication of percutaneous coronary interventions (PCIs) [1–4] with an incidence rate of around 1%, although probably underestimated due to reporting bias. Dedicated devices allow a high rate of successful retrieval during the same procedure. When this fails, emergency surgical intervention is often needed [2]. We present the case of a coronary balloon-angioplasty catheter entrapped in a poorly expanded stent inside the left anterior descending (LAD) artery with the body of the catheter severed inside the thoracic aorta after failed attempts of percutaneous retrieval. Intracoronary thrombosis developed, with myocardial ischaemia and cardiogenic shock. Emergency surgical retrieval and distal revascularization with bypass grafting was performed. CASE REPORT A 70-year old male with stable angina exhibited reversible ischaemia of the anterior wall on myocardial scintigraphy. His medical history was significant for insulin-dependent diabetes mellitus, atrial fibrillation, peripheral vascular disease and a previous aortic valve replacement with a mechanical prosthesis 5 years earlier. An elective coronary angiogram via the radial artery revealed a long and severely calcified lesion with 75% stenosis on the mid-LAD, distal to the first diagonal branch (Fig. 1). Based upon the in situ decision made outside the heart team discussion and despite many unfavourable predictors being present in this case, a rotational atherectomy of the lesion was performed with the Rotablator system (Boston Scientific Corporation, Natick, MA, USA), and two rapamycin-eluting stents were implanted (Tsunamed, Winsen, Germany). Incomplete expansion of the proximal stent was observed, and post-dilation was performed with a 2.5 × 11 mm non-compliant balloon (Mistral NC, Hexacath, France), which got stuck in the body of the stent. After different unsuccessful percutaneous extraction manoeuvres, the catheter was severed within the thoracic aorta at the level of the subclavian artery (Fig. 1D), and only the proximal end was retrieved. Intra-stent thrombosis occurred and the patient’s condition worsened with hypotension and ST-segment elevation. Cardiogenic shock rapidly developed with five episodes of ventricular fibrillation that required resuscitation manoeuvres, electrical defibrillation and intubation. An intra-aortic balloon pump (IABP) was inserted through the femoral artery. We decided to proceed emergently to the operating room, aiming to remove all foreign material and to restore flow in the LAD. Although the patient had been anticoagulated with low-molecular-weight heparin before admission and received 7500 units of unfractioned heparin immediately before starting the procedure, we decided to give an additional 15 000 units of unfractioned heparin at the cathlab for an activated clotting time of around 300 s to prevent complete intravascular thrombosis and embolization. To temporarily restore flow in the LAD, a guidewire was advanced and the entrapped balloon was crushed against the stent wall with another balloon obtaining a reasonable distal flow. The patient was immediately transferred to the operating room. Cardiopulmonary bypass (CPB) was established through femoral cannulation before redo sternotomy given his clinical condition. The ascending aorta was crossclamped using a Fogarty clamp, and combined antegrade and retrograde cardioplegia was sequentially administered. A transverse aortotomy was performed and the proximal portion of the catheter was retrieved from the distal aorta by pulling while gently releasing tension on the cross-clamp. With gentle rotation © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. G. Ventosa-Fernandez et al. / Interactive CardioVascular and Thoracic Surgery 141 and traction of the catheter at its entrance inside the ostium, the distal end of the balloon catheter could be completely removed (Fig. 2). A reversed saphenous vein graft was anastomosed to the LAD distally to the lesion and the underexpanded stent. After 36 min of aortic cross-clamp and 80 min of CPB, the patient was weaned in good condition. His postoperative course was uneventful, and the IABP was removed 48 h after the intervention. Postoperative angiography demonstrated complete occlusion of the LAD at the point of the catheter entrapment, with the stents in place and occluded. The vein graft was widely patent and the patient was discharged home after 14 days. Ten months after the procedure, the patient continues in excellent condition and echocardiography showed normal left ventricular function. DISCUSSION Device entrapment implies the presence of foreign material inside the coronary tree with variable degree of coronary flow impairment and endothelial injury and may act as a trigger for intracoronary thrombosis. Thrombus formation can propagate into the thoracic aorta or even the peripheral access artery, with the risk of subsequent embolization. Risk factors reported include previous rotational atherectomy, delivery through previously implanted stents, bifurcation lesions, calcified and tortuous vessels, overlapping stents and the use of hydrophilic wires [1, 2]. Currently, different devices are available allowing a high rate of percutaneous retrieval during the same procedure [1, 2]. Nev (...truncated)