Abstract 4146986: Removal of the Entrapped distal embolic protection system behind the stent frame during the percutaneous intervention of critically stenosed Saphenous venous graft. A Case Report.

Case Description and Procedural Technique: 86 year old female with a prior history of coronary artery bypass grafting presented with non-ST elevation MI underwent subtotal occlusion of vein graft supplying the large obtuse marginal artery. The left coronary bypass catheter was used to cannulate the vein graft, supplying the obtuse marginal artery. Balanced middleweight universal wire (BMW) was used to cross the lesion. Given the critical nature of the lesion, it was pre-dilated using a 2 mm balloon. Bare wire and emboshield NAV6 (2.5-4.8mm) embolic protection was then used for distal protection. Due to hemodynamically intolerance, direct stenting was opted for, and a 3.5 x 16 mm synergy stent was deployed over the BMW wire with accidental entrapment of the bare wire and embossed filter protection system behind the stent frame. We have then placed an un-inflated 2.5 mm balloon inside the stent frame over the BMW wire. A 1 mm sapphire balloon was advanced over the bare wire, and its distal tip was placed behind the proximal edge of the stent. It was then inflated at 8 atmospheres. Serial inflations behind the stent frame were done with slow advancement of the balloon, covering the entire length of the stent. The balloon was then upsized to 2 mm, and serial inflations were performed behind the stent frame. After creating enough lumen, the filter was pulled back and re-captured. The 2.5 mm balloon was then inflated inside the stent frame. The balloon was upsized to 3.5 mm for the good apposition of the stent frame. TIMI III flow was obtained without any complications. Discussion: Distal embolic protection with intravascular filters is often used during percutaneous intervention of saphenous venous grafts. Accidental entrapment of emboshield filter systems can occur behind the stent in emergent situations when buddy wire technique is used in the vein graft. Our technique describes removal of the entrapped filter in a safe manner keeping the stent frame in place without surgical intervention. A few similar cases have been reported in the literature with surgical removal of wire.