Cardiovasc Interv and Ther DOI 10.1007/s12928-015-0320-x

CASE REPORT

Stent dislodgement induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome Masahiro Nishi • Kan Zen • Daisuke Kambayashi Satoshi Asada • Shinichiro Yamaguchi • Hirotaka Tatsukawa



Received: 17 December 2014 / Accepted: 24 January 2015 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2015

Abstract Coronary stent dislodgement is a rare but critical complication of percutaneous coronary intervention. It can potentially result in serious consequences, such as stent embolization and emergent coronary artery bypass graft surgery. Here, we describe the successful retrieval of an extracoronary dislodged stent, where dislodgement was induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome. Keywords Stent dislodgement  Kounis syndrome  Coronary spasm  Lidocaine allergy Introduction Coronary stent dislodgement is an uncommon complication of modern percutaneous coronary intervention (PCI). However, it has a potential risk of serious consequences, such as myocardial infarction due to stent embolization, ischemic neurologic deficit and emergent coronary artery bypass graft (CABG) surgery [1]. Kounis syndrome is characterized by the concurrence of acute coronary events involving coronary spasm and allergy or hypersensitivity [2]. In this case, coronary stent dislodgement was induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome. Lidocaine allergy caused Kounis syndrome, which occurred during a PCI procedure. Consequently, we were able to retrieve the extracoronary dislodged stent by using a gooseneck snare catheter. M. Nishi (&)  K. Zen  D. Kambayashi  S. Asada  S. Yamaguchi  H. Tatsukawa Department of Cardiology, Omihachiman Community Medical Center, Tsuchidacho 1379, Omihachiman, Shiga, Japan e-mail: [email protected]

Case report A 79-year-old man was brought to the emergency room by ambulance with prolonged chest pain that had lasted for 6 h. His comorbidities were diabetes mellitus, dyslipidemia, polymyalgia rheumatica (PMR) and habitual smoking. He was taking 5 mg of prednisolone per day for PMR. There was no history of allergy. Height was 165 cm and weight was 68 kg. Upon admission, the laboratory results showed an elevated level of cardiac enzymes and an electrocardiogram showed ST elevation in leads II, III, and aVf, which indicated acute inferior myocardial infarction. Emergent coronary angiography (CAG) revealed the total occlusion of the proximal right coronary artery (RCA) and 90 % stenosis in the middle part of the left anterior descending artery (LAD). Direct PCI with a zotarolimus eluting stent (ZES) (Resolute Integrity; Medtronic, Minneapolis, MN, USA) was performed for the RCA occlusive lesion. The patient was admitted to the coronary care unit following the procedure. His post treatment course was good with the exception of exacerbation of PMR. PMR was relieved by increased administration of prednisolone in doses of up to 10 mg per day. Staged-PCI was then performed for the residual significant stenosis in the LAD (Fig. 1a, b). Approaching from the left radial artery, a SheathLess 6.5 Fr JL4.0 (ASAHI INTECC, Nagoya, Aichi, Japan) guiding catheter was engaged into the left coronary artery (LCA) and a 0.014inch wire was advanced easily through the LAD. Predilatation was performed using a 3.5 mm balloon, and a 3.5/15 mm ZES was deployed in the middle part of the LAD. Immediately following the procedure, the patient experienced sudden chest pain, wheezing, altered consciousness, atrial fibrillation tachycardia (140 bpm), and a remarkable decrease in blood pressure (70/40 mmHg) and

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M. Nishi et al. Fig. 1 a Angiographies of right anterior oblique (RAO) cranial view and b RAO caudal view show significant stenosis in the left anterior descending artery (LAD)

appeared flushed in the face. A CAG revealed 99 % of severe stenosis at the proximal edge of the stent and subtotal occlusion of the left circumflex artery (LCX) with delayed flow of the contrast media (Fig. 2a). Anaphylaxis and coronary spasm presumably occurred at the same time, and therefore, isosorbide dinitrate (ISDN) was administered into the LCA, which helped to eliminate the severe spasm (Fig. 2b). Circulatory and respiratory symptoms were relieved following intravenous administration of methylprednisolone sodium succinate and antihistamine (dexchlorpheniramine) agent was administered for anaphylactic symptoms. Intravascular ultrasound (IVUS) imaging detected a normal appearance of the stent; however, there was a cavity in the proximal part of the LAD (Fig. 2c). The diameter of the proximal part of the LAD was 4.3 mm, which was measured by fluoroscopy in advance before PCI procedure. Therefore, a 3.5/15 mm ZES was deployed using rated burst pressure, to overlap the previous stent in the LAD. Post-dilatation was performed with a 4.0/10 mm balloon. However, the newly

implanted stent accidentally vanished off the screen following post-dilatation. Extracoronary stent dislodgement might have occurred by the stent being pulled by the balloon that was used for post-dilatation. Fortunately, the stent could be detected surrounding the guiding catheter in the ascending aorta (Fig. 3a). We deployed a 4.0/15 mm bare metal stent followed by post-dilatation with a 5.0 mm noncompliant balloon before we attempted to retrieve the dislodged stent. The tip of the guiding catheter was then capped with a dilated 4.0 mm balloon to prevent the stent from falling into the artery. By pulling the guiding catheter, we were able to move the dislodged stent from the intraaorta to the left subclavian artery distal from the bifurcation of the left vertebral artery to avoid cerebral embolism (Fig. 3b). We attempted to capture the stent by a gooseneck snare catheter (Amplatz GooseNeck Snare Kit; ev3/COVIDIEN, Mansfield, MA, USA) from the left radial artery; however, the procedure was unsuccessful because of the anatomically difficult angulation of the left subclavian artery. We inserted an 8 Fr sheath into the right femoral

Fig. 2 a An angiography of right anterior oblique (RAO) caudal view reveals severe coronary spasm in the left anterior descending artery (LAD) and the left circumflex artery (LCX). b The spasm was

removed after isosorbide dinitrate (ISDN) administration. c Intravascular ultrasound (IVUS) detected a cavity in the direction of 2 o0 clock

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Stent dislodgement induced by a vasodilator

Fig. 3 a The dislodged stent (red arrow) surrounding the guiding catheter in the ascending aorta. b Blue arrow shows a 4.0 mm balloon that caps the tip of the guiding catheter and red arrow shows the

dislodged stent surrounding the guiding catheter. c The dislodged stent (red arrow) is being removed from the right femoral artery by using the gooseneck snare catheter (blue arrow)

artery, and we were then able to capture and remove the dislodged stent using the gooseneck snare catheter retrogradely (Fig. 3c). Following the PCI procedure, a drug induced lymphocyte stimulation test (DLST) was performed as we suspected the patient had experienced an allergic reaction to either the 1 % lidocaine used for local anesthesia, the contrast media or zotarolimus. The DLST results determined that lidocaine was the cause of the consecutive allergic reaction.

vasodilation by ISDN caused the geographical miss about the vessel diameter, resulting in the implantation of the undersized stent. In the end, the dislodged stent could be retrieved from the right femoral artery using the gooseneck snare catheter without any serious complications. If we inserted an 8 Fr sheath alternatively into the left radial artery, it might enable to retrieve the dislodged stent from the left radial artery. Kounis syndrome is characterized by acute coronary events involving coronary spasm triggered by allergy or hypersensitivity. Vasoconstrictor stimuli such as histamine or leukotriene released by mast cell degranulation triggered by undefined causes can cause coronary spasm because of a nonspecific hyper-reactive response of the vascular smooth muscle cells in the coronary artery [5]. In the case presented here, DLST revealed that the 1 % lidocaine used for local anesthesia was the cause of Kounis syndrome. There are few published reports that have shown an association between lidocaine and Kounis syndrome. This is a rare case of Kounis syndrome, caused by a lidocaine allergy, which occurred during a PCI procedure.

Discussion Coronary stent dislodgement is an uncommon complication of modern PCI, and its incidence has decreased owing to the technological development and the universal use of premounted stents [3]. However, when stent dislodgement does occur, it can potentially result in serious consequences, such as myocardial infarction due to stent embolization, ischemic neurologic deficit and emergent CABG surgery. Stent dislodgement is more likely to occur during stent retraction into the guiding catheter, or in lesions with calcification or proximal angulation before the stent is deployed [4]. In the case presented here, the stent was dislodged following full expansion by rated burst pressure in the lesion of the LAD. It was likely to have occurred because the coronary artery diameter was extended beyond the optimal stent size due to the effect of ISDN and in addition, because the large (4.0 mm) non-compliant balloon used for post-dilatation, which was insufficiently rewrapped after use, might have hooked the stent and dislodged it as the balloon was pulled back. We reviewed the findings of IVUS that was done after ISDN removed the severe spasm, which showed that the vessel diameter of the proximal part of the LAD was 5.5 mm, although the diameter was measured 4.3 mm by fluoroscopy in advance before PCI procedure. Therefore, we can conclude that the

Conclusion We describe the successful retrieval of an extracoronary dislodged stent, where dislodgement was induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome. Conflict of interest

None.

References 1. Bolte J, Neumann U, Pfafferott C, Vogt A, Engel HJ, Mehmel HC, von Olshausen KE. Incidence, management, and outcome of stent loss during intracoronary stenting. Am J Cardiol. 2001;88(5):565–7.

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M. Nishi et al. 2. Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm? Int J Cardiol. 2006;110(1):7–14. 3. Eggebrecht H, Haude M, von Birgelen C, Oldenburg O, Baumgart D, Herrmann J, Welge D, Bartel T, Dagres N, Erbel R. Nonsurgical retrieval of embolized coronary stents. Catheter Cardiovasc Interv. 2000;51(4):432–40. 4. Brilakis ES, Best PJ, Elesber AA, Barsness GW, Lennon RJ, Holmes DR Jr, Rihal CS, Garratt KN. Incidence, retrieval

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methods, and outcomes of stent loss during percutaneous coronary intervention: a large single- center experience. Catheter Cardiovasc Interv. 2005;66(3):333–40. 5. Lanza GA, Careri G, Crea F. Mechanism of coronary artery spasm. Circulation. 2011;124(16):1774–82.

Stent dislodgement induced by a vasodilator used for severe coronary artery spasm caused by Kounis syndrome.

Coronary stent dislodgement is a rare but critical complication of percutaneous coronary intervention. It can potentially result in serious consequenc...
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