SS–18 Management of Aorto-Ostial Stent Protrusion Using the Side Flap Technique in Acute Coronary Syndrome Developing During Chemotherapy: A Case Report

Abstract

Introduction and Aim: Aorto-ostial stent implantation is a technically challenging percutaneous coronary intervention due to anatomical considerations and difficulties in achieving optimal stent positioning. Stent protrusion into the aorta may make subsequent re-entry into the stent lumen difficult and compromise adequate catheter support during further interventions. The Side Flap technique is an alternative approach that enables the creation of a new functional lumen by passing through the side wall of the stent in selected cases where re-entry into the original stent lumen is not feasible. In this case, we present the successful management of aorto-ostial stent protrusion using the Side Flap technique during coronary intervention performed for chest pain and elevated troponin levels that developed during chemotherapy.

Case Report: A 65-year-old man with a history of hypertension and coronary artery disease, including previous coronary stent implantation, was admitted for evaluation of chest pain and elevated troponin levels that developed during chemotherapy for lung cancer. Electrocardiography showed sinus rhythm. Echocardiography revealed a left ventricular ejection fraction of 60%, mild mitral and tricuspid regurgitation, and grade 1 diastolic dysfunction. Coronary angiography demonstrated an 80% stenosis at the LAD ostium, a patent stent in the mid-LAD segment, a 30% stenosis in the CX-OM2 segment, and severe stenoses in the ostial (90%) and mid (95%) segments of the nondominant RCA. Percutaneous coronary intervention (PCI) to the LAD was planned, and the left main coronary artery (LMCA) was engaged with a 7-French 3.5 guiding catheter. After wiring the LAD and CX, balloon angioplasty of the LAD was performed using a 2.0×25 mm balloon. Subsequently, a 3.5×38 mm drug-eluting stent (DES) was deployed from the LMCA ostium into the LAD. The stent was assessed in different angiographic projections and positioned with 1–2 struts extending into the aorta. During stent deployment, the patient took a deep inspiration, resulting in approximately 10 mm of stent protrusion into the aorta. Because of the stent protrusion into the LMCA ostium, inability to re-cross the stent lumen with a guidewire, and compromised CX flow, the guidewire was advanced from the LMCA into the LAD by passing through the edge of the protruding stent struts. At this stage, the Side Flap technique was performed using a 3.5×10 mm balloon, resulting in lateral displacement of the protruding stent segment and creation of a functional lumen. Proximal optimization technique (POT) was then performed in the LMCA using a 5.0×8 mm balloon. A 3.5×23 mm DES was implanted between the two stents in the LAD. The CX was rewired with a floppy guidewire, and the stent struts were dilated using a 2.5×15 mm balloon. A 3.0×34 mm DES was subsequently implanted in the CX using the TAP technique. After kissing-balloon dilatation with 3.0×12 mm and 3.5×12 mm non-compliant balloons, final POT was performed using a 5.0×8 mm non-compliant balloon (Video 1). The patient was prescribed dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. Follow-up coronary angiography was planned for 6 months later. However, approximately 5 months later, the patient died following the development of hemoptysis.

Conclusion: Aorto-ostial stent protrusion can significantly complicate re-entry into the stent lumen, particularly during complex bifurcation procedures. The Side Flap technique may offer an alternative solution in selected cases where re-entry into the original stent lumen is not feasible. This case demonstrates that aorto-ostial stent protrusion in complex LMCA-LAD-CX bifurcation anatomy can be successfully managed using the Side Flap technique in combination with the TAP technique.