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Vascular OnlineFirst, published on May 12, 2014 as doi:10.1177/1708538114535393
Case Report
Trapped cerebral thrombectomy device: A case report of a rare complication
Vascular 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114535393 vas.sagepub.com
Guillaume SC Geuzebroek1, Jan Wille1, Jean-Paul de Vries1, Wouter Schonewille2 and Jan-Albert Vos3
Abstract Intravenous thrombolysis with recombinant tissue plasminogen activator is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset. Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances. Intra-arterial thrombolysis and/ or intra-arterial thrombectomy can overcome these drawbacks and even increase the rate of recanalization. While intravenous thrombolysis is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe the multidisciplinary approach of a rare complication of a trapped mechanical thrombectomy device.
Keywords Intra-arterial, thrombectomy, trapped, complication, ischaemic stroke, therapy
Introduction Acute ischaemic stroke causes substantial morbidity and mortality. A 30-day mortality rate up to 20% is reported but has been significantly declined over the last decades due to improved imaging and treatment modalities.1 Favourable clinical outcome in patients with proximal cerebral artery occlusion is highly dependent on recanalization and time to reperfusion.2 Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rtPA) is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset.3 Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances (e.g. trauma, recent history of surgery or stroke). Furthermore, not all patients benefit from IVT. Especially, occlusions of larger cerebropetal vessels (M1/M2 segments of the middle cerebral artery, MCA) and basilar artery are known to have limited benefit. Intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT) can potentially overcome these drawbacks of IVT and improve recanalization rates.4,5 Mechanical thrombectomy aims to directly remove the cloth endovascular in the occluded vessel. Several techniques have been used. The techniques that are mainly used are direct suction by a micro-catheter
or extracting the thrombus by placing a small corkscrew looking stent behind the thrombus or a stent within the thrombus. Case series of patients treated with MT devices have consistently shown higher recanalization rates as compared to IAT alone. Randomized trials have shown that the use of retrievable stents can further improve recanalization rates as compared to early generation thrombectomy devices.6,7 However, recently several randomized controlled trials did not show a clinically superior outcome of intra-arterial treatment compared to IVT alone.8–10 While IVT is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe 1 Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands 2 Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands 3 Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
Corresponding author: Guillaume SC Geuzebroek, Department of Vascular Surgery, St. Antonius Hospital, PO 2500, 3430EM Nieuwegein, the Netherlands. Email: [email protected]
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the multidisciplinary approach of a rare complication of a trapped MT device.
Case A 65-year-old male patient with a past medical history of hypertension and hypercholesterolaemia presented with a gaze preference towards the left, aphasia, and a right-sided hemiparesis. A computed tomography angiography of the brain showed an occluded MCA, and IVT was initiated within 1.5 h of stroke onset. He was transferred to our tertiary referral stroke centre and included in the MR CLEAN trial (NTR1804). This trial compares IAT and/or MT with no intraarterial therapy in addition to standard treatment (including IVT). He was randomized for intra-arterial intervention. Mechanical intra-arterial thrombectomy was commenced within 4 h of symptom onset. Percutaneous access was achieved via the right common femoral artery. Owing to severe elongation of the arch vessels, the balloon guiding catheter (Merci, Concentric Medical Inc, Mountain View, CA, USA) could not be advanced more than 6 cm into the common carotid artery (CCA). Angiography showed 99% stenosis of the proximal left internal carotid artery (ICA) with insufficient space to pass with the catheter for the retrieval device (Figure 1(a)). First, a percutaneous transluminal angioplasty (PTA) with a 3-mm balloon and subsequently with a 5-mm balloon was performed, but still not enough space could be created to pass the catheters into the ICA. Consequently, a 7/10 40mm Cristallo Ideale stent (Invatec S.p.A, Roncadelle, Italy), a dedicated carotid bifurcation stent, was implanted (Figure 1(b)) to overcome the severe stenosis in the proximal ICA. Subsequently, a distal access catheter (DAC, Concentric Medical Inc) was placed into the distal ICA, and through this DAC, a micro-catheter (Progreat 2.7, Terumo, Somerset, NJ, USA) was positioned in the MCA distal to the thrombus (Figure 1(c)). The thrombus was mechanically extracted using a Trevo device (Concentral Medical Inc). The Trevo device is a so-called retrievable stent deployed within the occluding thrombus and left in place during several minutes to ‘catch’ the thrombus after which the device is pulled out. The thrombus was successfully extracted from the MCA. As the balloon guiding catheter could not pass into the ICA, the plan was to pull the retriever into the DAC before passing through the stent. However, when it was retracted to just above the level of the stent, the patient became agitated and moved his head. Fluoroscopy and a subsequent angiography then showed that the Trevo device was trapped in the carotid stent (Figure 1(d)).
Figure 1. Subtraction angiography showing a subtotal stenosis of the left internal carotid artery (arrow) (a). Subtraction angiography after PTA with stent (b). Subtraction angiography showing a mid occlusion of the middle cerebral artery (arrow) (c). Fluoroscopy showing the Trevo device hooked into the stent (d).
The intervention radiologist was unable to extract the device, despite elaborate but careful manipulation. After careful multidisciplinary consultation with the vascular surgeon and neurologist, surgical removal was deemed necessary. Before surgery was started, the patient was treated with 500 IE heparin per hour. Under Transcranial Doppler (TCD) and electroencephalogram (EEG) monitoring, a more or less routine carotid endarterectomy was performed (Figure 2). Exposure to the left carotid artery was achieved by an oblique incision parallel to the sternocleidomastoid muscle. Thereafter, the common carotid, internal carotid, external carotid and superior thyroid artery were clamped. The TCD showed a 36% decrease of flow in the MCA. No shunt was inserted, because the EEG was
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Figure 2. The common and internal carotid artery is opened. The stent is visible wherein the mechanical thrombectomy device is trapped. Proximal in the carotid artery, the catheter is visible.
Figure 4. Inside the stent, the thrombectomy device is clearly visible.
Figure 3. Explanted carotid stent with the trapped thrombectomy device.
unaffected after clamping. We opened the CCA and ICA, where after the stent was clearly visible (Figure 2). The DAC was cut and retrieved from the right groin. Thereafter, the stent and Trevo device could easily be extracted. An endarterectomy of the CCA and ICA was performed and followed by a bovine patch angioplasty. Figures 3 and 4 show the explanted carotid stent with the trapped Trevo device inside. Despite the trapped device and carotid endarterectomy, no deterioration of the clinical situation of the patient occurred. Six days post-operatively, the patient was discharged from the hospital.
Discussion This case report describes a rare complication of intraarterial thrombectomy for acute ischaemic stroke. Technical complications of endovascular procedures are well known. Trapped devices are, however, less
common, especially when it requires surgery to extract the device. Cases of trapped devices are predominantly described in the context of cardiac intervention, such as broken guidewires,11 trapped guidewires,12 trapped stents13 and trapped catheters in access vessels.14 Less commonly described are trapped devices during peripheral vascular percutaneous intervention, but they potentially harbour the same problems as with coronary interventions.15 Literature concerning trapped devices during carotid or cerebral endovascular which required surgery is limited to one other case report of an entrapped cerebral protection system in a carotid stent for which surgery was necessary to extract the device.16 When a device is lost during an endovascular procedure, several options are available to extract it, such as snares, endovascular forceps or balloons. However, in case of trapped devices the situation is, however, more complex and endovascular options are limited. If careful manipulation does not result in liberating the device, surgery is generally required. The best timing of surgical removal depends on the specifics of the device and the clinical condition of the patient. The direct cause of the device being trapped in this particular case was a sudden head movement. Other more frequent complications of intracranial procedures which may be induced by sudden head movement are dissection, perforation or rupture of the large arteries. Immobilization of a patient’s head during the procedure is often not an easy task. Acute stroke patients often have a lower state of consciousness and are
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therefore less amenable to follow instructions and may be restless. Furthermore, the manipulation of intracranial vessels by endovascular devices may be very painful, causing agitation. Some operators therefore advise general anaesthesia (GA) for intra-arterial stroke treatment. In our tertiary referral centre, we do not routinely use GA for acute stroke treatment as it inhibits the neurologic evaluation during and immediately after the procedure and may increase the risk of respiratory complications. One could consider to immobilize the patient’s head to reduce the chance of this kind of complications. The ongoing technical development allows us to expand our treatment options. In general, more and more procedures are performed minimally invasive or with sole endovascular means. While endovascular or intra-arterial therapy for acute ischaemic stroke potentially has major advantages, it carries the risk of its own complications. A multidisciplinary vascular team is key for success when such complications occur and surgical surgery may be the only option. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Feigin VL, Lawes CM, Bennett DA, et al. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 2009; 8: 355–369. 2. Khatri P, Abruzzo T, Yeatts SD, et al. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 2009; 73: 1066–1072. 3. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581–1587.
4. Saver JL. Intra-arterial fibrinolysis for acute ischemic stroke: the message of melt. Stroke 2007; 38: 2627–2628. 5. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 2008; 39: 1205–1212. 6. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380: 1231–1240. 7. Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallelgroup, non-inferiority trial. Lancet 2012; 380: 1241–1249. 8. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368: 904–913. 9. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus tPA alone for stroke. N Engl J Med 2013; 368: 893–903. 10. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013; 368: 914–923. 11. Balbi M, Bezante GP, Brunelli C, et al. Guide wire fracture during percutaneous transluminal coronary angioplasty: possible causes and management. Interact Cardiovasc Thorac Surg 2010; 10: 992–994. 12. Kotoulas C, Stathopoulos I, Koukis I, et al. Surgical release of trapped guidewire after coronary angioplasty and stenting. Asian Cardiovasc Thorac Ann 2009; 17: 439. 13. C¸ic¸ek D and Pekdemir H. A rare and avoidable complication of percutaneous coronary intervention: stent trapped in the left main coronary artery and its unusual treatment. Hellenic J Cardiol 2011; 52: 367–370. 14. Kim JY, Moon KW and Yoo KD. Entrapment of a kinked catheter in the radial artery during transradial coronary angiography. J Invasive Cardiol 2012; 24: E3–E4. 15. Gabrielli R, Rosati MS, Millarelli M, et al. Surgical removal of a ruptured, detached angioplasty balloon after popliteal stenting. Thorac Cardiovasc Surg 2011; 59: 375–377. 16. Faggioli GL, Ferri M, Rossi C, et al. Carotid stent failure: results of surgical rescue. Eur J Vasc Endovasc Surg 2007; 33: 58–61.
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(VAS)
[1–4] [PREPRINTER stage]
Vascular OnlineFirst, published on May 12, 2014 as doi:10.1177/1708538114535393
Case Report
Trapped cerebral thrombectomy device: A case report of a rare complication
Vascular 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114535393 vas.sagepub.com
Guillaume SC Geuzebroek1, Jan Wille1, Jean-Paul de Vries1, Wouter Schonewille2 and Jan-Albert Vos3
Abstract Intravenous thrombolysis with recombinant tissue plasminogen activator is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset. Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances. Intra-arterial thrombolysis and/ or intra-arterial thrombectomy can overcome these drawbacks and even increase the rate of recanalization. While intravenous thrombolysis is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe the multidisciplinary approach of a rare complication of a trapped mechanical thrombectomy device.
Keywords Intra-arterial, thrombectomy, trapped, complication, ischaemic stroke, therapy
Introduction Acute ischaemic stroke causes substantial morbidity and mortality. A 30-day mortality rate up to 20% is reported but has been significantly declined over the last decades due to improved imaging and treatment modalities.1 Favourable clinical outcome in patients with proximal cerebral artery occlusion is highly dependent on recanalization and time to reperfusion.2 Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rtPA) is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset.3 Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances (e.g. trauma, recent history of surgery or stroke). Furthermore, not all patients benefit from IVT. Especially, occlusions of larger cerebropetal vessels (M1/M2 segments of the middle cerebral artery, MCA) and basilar artery are known to have limited benefit. Intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT) can potentially overcome these drawbacks of IVT and improve recanalization rates.4,5 Mechanical thrombectomy aims to directly remove the cloth endovascular in the occluded vessel. Several techniques have been used. The techniques that are mainly used are direct suction by a micro-catheter
or extracting the thrombus by placing a small corkscrew looking stent behind the thrombus or a stent within the thrombus. Case series of patients treated with MT devices have consistently shown higher recanalization rates as compared to IAT alone. Randomized trials have shown that the use of retrievable stents can further improve recanalization rates as compared to early generation thrombectomy devices.6,7 However, recently several randomized controlled trials did not show a clinically superior outcome of intra-arterial treatment compared to IVT alone.8–10 While IVT is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe 1 Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands 2 Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands 3 Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
Corresponding author: Guillaume SC Geuzebroek, Department of Vascular Surgery, St. Antonius Hospital, PO 2500, 3430EM Nieuwegein, the Netherlands. Email: [email protected]
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the multidisciplinary approach of a rare complication of a trapped MT device.
Case A 65-year-old male patient with a past medical history of hypertension and hypercholesterolaemia presented with a gaze preference towards the left, aphasia, and a right-sided hemiparesis. A computed tomography angiography of the brain showed an occluded MCA, and IVT was initiated within 1.5 h of stroke onset. He was transferred to our tertiary referral stroke centre and included in the MR CLEAN trial (NTR1804). This trial compares IAT and/or MT with no intraarterial therapy in addition to standard treatment (including IVT). He was randomized for intra-arterial intervention. Mechanical intra-arterial thrombectomy was commenced within 4 h of symptom onset. Percutaneous access was achieved via the right common femoral artery. Owing to severe elongation of the arch vessels, the balloon guiding catheter (Merci, Concentric Medical Inc, Mountain View, CA, USA) could not be advanced more than 6 cm into the common carotid artery (CCA). Angiography showed 99% stenosis of the proximal left internal carotid artery (ICA) with insufficient space to pass with the catheter for the retrieval device (Figure 1(a)). First, a percutaneous transluminal angioplasty (PTA) with a 3-mm balloon and subsequently with a 5-mm balloon was performed, but still not enough space could be created to pass the catheters into the ICA. Consequently, a 7/10 40mm Cristallo Ideale stent (Invatec S.p.A, Roncadelle, Italy), a dedicated carotid bifurcation stent, was implanted (Figure 1(b)) to overcome the severe stenosis in the proximal ICA. Subsequently, a distal access catheter (DAC, Concentric Medical Inc) was placed into the distal ICA, and through this DAC, a micro-catheter (Progreat 2.7, Terumo, Somerset, NJ, USA) was positioned in the MCA distal to the thrombus (Figure 1(c)). The thrombus was mechanically extracted using a Trevo device (Concentral Medical Inc). The Trevo device is a so-called retrievable stent deployed within the occluding thrombus and left in place during several minutes to ‘catch’ the thrombus after which the device is pulled out. The thrombus was successfully extracted from the MCA. As the balloon guiding catheter could not pass into the ICA, the plan was to pull the retriever into the DAC before passing through the stent. However, when it was retracted to just above the level of the stent, the patient became agitated and moved his head. Fluoroscopy and a subsequent angiography then showed that the Trevo device was trapped in the carotid stent (Figure 1(d)).
Figure 1. Subtraction angiography showing a subtotal stenosis of the left internal carotid artery (arrow) (a). Subtraction angiography after PTA with stent (b). Subtraction angiography showing a mid occlusion of the middle cerebral artery (arrow) (c). Fluoroscopy showing the Trevo device hooked into the stent (d).
The intervention radiologist was unable to extract the device, despite elaborate but careful manipulation. After careful multidisciplinary consultation with the vascular surgeon and neurologist, surgical removal was deemed necessary. Before surgery was started, the patient was treated with 500 IE heparin per hour. Under Transcranial Doppler (TCD) and electroencephalogram (EEG) monitoring, a more or less routine carotid endarterectomy was performed (Figure 2). Exposure to the left carotid artery was achieved by an oblique incision parallel to the sternocleidomastoid muscle. Thereafter, the common carotid, internal carotid, external carotid and superior thyroid artery were clamped. The TCD showed a 36% decrease of flow in the MCA. No shunt was inserted, because the EEG was
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Figure 2. The common and internal carotid artery is opened. The stent is visible wherein the mechanical thrombectomy device is trapped. Proximal in the carotid artery, the catheter is visible.
Figure 4. Inside the stent, the thrombectomy device is clearly visible.
Figure 3. Explanted carotid stent with the trapped thrombectomy device.
unaffected after clamping. We opened the CCA and ICA, where after the stent was clearly visible (Figure 2). The DAC was cut and retrieved from the right groin. Thereafter, the stent and Trevo device could easily be extracted. An endarterectomy of the CCA and ICA was performed and followed by a bovine patch angioplasty. Figures 3 and 4 show the explanted carotid stent with the trapped Trevo device inside. Despite the trapped device and carotid endarterectomy, no deterioration of the clinical situation of the patient occurred. Six days post-operatively, the patient was discharged from the hospital.
Discussion This case report describes a rare complication of intraarterial thrombectomy for acute ischaemic stroke. Technical complications of endovascular procedures are well known. Trapped devices are, however, less
common, especially when it requires surgery to extract the device. Cases of trapped devices are predominantly described in the context of cardiac intervention, such as broken guidewires,11 trapped guidewires,12 trapped stents13 and trapped catheters in access vessels.14 Less commonly described are trapped devices during peripheral vascular percutaneous intervention, but they potentially harbour the same problems as with coronary interventions.15 Literature concerning trapped devices during carotid or cerebral endovascular which required surgery is limited to one other case report of an entrapped cerebral protection system in a carotid stent for which surgery was necessary to extract the device.16 When a device is lost during an endovascular procedure, several options are available to extract it, such as snares, endovascular forceps or balloons. However, in case of trapped devices the situation is, however, more complex and endovascular options are limited. If careful manipulation does not result in liberating the device, surgery is generally required. The best timing of surgical removal depends on the specifics of the device and the clinical condition of the patient. The direct cause of the device being trapped in this particular case was a sudden head movement. Other more frequent complications of intracranial procedures which may be induced by sudden head movement are dissection, perforation or rupture of the large arteries. Immobilization of a patient’s head during the procedure is often not an easy task. Acute stroke patients often have a lower state of consciousness and are
Downloaded from vas.sagepub.com at WASHINGTON UNIV SCHL OF MED on January 13, 2015
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therefore less amenable to follow instructions and may be restless. Furthermore, the manipulation of intracranial vessels by endovascular devices may be very painful, causing agitation. Some operators therefore advise general anaesthesia (GA) for intra-arterial stroke treatment. In our tertiary referral centre, we do not routinely use GA for acute stroke treatment as it inhibits the neurologic evaluation during and immediately after the procedure and may increase the risk of respiratory complications. One could consider to immobilize the patient’s head to reduce the chance of this kind of complications. The ongoing technical development allows us to expand our treatment options. In general, more and more procedures are performed minimally invasive or with sole endovascular means. While endovascular or intra-arterial therapy for acute ischaemic stroke potentially has major advantages, it carries the risk of its own complications. A multidisciplinary vascular team is key for success when such complications occur and surgical surgery may be the only option. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Feigin VL, Lawes CM, Bennett DA, et al. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 2009; 8: 355–369. 2. Khatri P, Abruzzo T, Yeatts SD, et al. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 2009; 73: 1066–1072. 3. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581–1587.
4. Saver JL. Intra-arterial fibrinolysis for acute ischemic stroke: the message of melt. Stroke 2007; 38: 2627–2628. 5. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 2008; 39: 1205–1212. 6. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380: 1231–1240. 7. Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallelgroup, non-inferiority trial. Lancet 2012; 380: 1241–1249. 8. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368: 904–913. 9. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus tPA alone for stroke. N Engl J Med 2013; 368: 893–903. 10. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013; 368: 914–923. 11. Balbi M, Bezante GP, Brunelli C, et al. Guide wire fracture during percutaneous transluminal coronary angioplasty: possible causes and management. Interact Cardiovasc Thorac Surg 2010; 10: 992–994. 12. Kotoulas C, Stathopoulos I, Koukis I, et al. Surgical release of trapped guidewire after coronary angioplasty and stenting. Asian Cardiovasc Thorac Ann 2009; 17: 439. 13. C¸ic¸ek D and Pekdemir H. A rare and avoidable complication of percutaneous coronary intervention: stent trapped in the left main coronary artery and its unusual treatment. Hellenic J Cardiol 2011; 52: 367–370. 14. Kim JY, Moon KW and Yoo KD. Entrapment of a kinked catheter in the radial artery during transradial coronary angiography. J Invasive Cardiol 2012; 24: E3–E4. 15. Gabrielli R, Rosati MS, Millarelli M, et al. Surgical removal of a ruptured, detached angioplasty balloon after popliteal stenting. Thorac Cardiovasc Surg 2011; 59: 375–377. 16. Faggioli GL, Ferri M, Rossi C, et al. Carotid stent failure: results of surgical rescue. Eur J Vasc Endovasc Surg 2007; 33: 58–61.
Downloaded from vas.sagepub.com at WASHINGTON UNIV SCHL OF MED on January 13, 2015
