A 70-year man was brought in hospital by ambulance after waking up at midnight with back pain and shortness of breath. He was hemodynamically stable with bilateral symmetrical pulses and normal neurology. ECG showed inferior ST-elevation. He was brought in hospital for emergent cardiac catheterization. 

Hemoglobin 155 g/LSerum Creatinine 95 micromol/Lhs Troponin T 217 ng/LEchocardiogram showed normal left ventricular systolic function with inferior wall hypokinesis. 

Successful percutaneous coronary intervention (PCI) of occluded right coronary artery was performed with a long drug-eluting stent (DES). Severe long proximal LAD disease with involvement of the distal left main (LM) artery was considered for staged PCI as patient declined surgery.

Via right radial approach, a 7.5F PB 3.0 sheathless Eaucath guide catheter was engaged in left coronary artery.  Intravascular ultrasound (IVUS) showed LM involvement and significant LAD-LM size mismatch. After stenting of LAD with a 4 x 38 mm DES, the LM was stented with a 5 x 8 mm DES with minimal overlap. Vigorous patient movement at the time of stent deployment resulted in dislodgement and proximal displacement of the stent. Fluoroscopy revealed the dislodged LM stent had drifted up towards the right subclavian artery over the guide catheter. LM stenting procedure was first safely completed by deployment of a 5 x 12 mm DES and post-dilated with a 6 mm non-compliant balloon. The drifting stent was then captured by the balloon at proximal end and brought back to brachial artery by simultaneous withdrawal of the balloon and the guide catheter, where the stent was secured and deployed. Inflation of BP cuff at high pressure at upper right arm did not cause any stent deformation. Patient was discharged next day in stable condition without any adverse outcome. 

This was an interesting case of PCI of left main artery complicated by proximal displacement and dislodgement of the stent into the aorta and drifting of the dislodged stent over the guiding catheter. The displaced stent was safely captured by balloon trapping and retracted by simultaneous withdrawal of the guide and balloon catheters proximally, to be deployed in the brachial artery. This was an unusual complication related to abrupt patient movement during stent deployment in the left main artery. Maintaining wire position is the key to avoid losing the stent in the circulation which can then be safely manipulated to a size-matched peripheral vessel for deployment.