Ostial Right Coronary Artery Stent Loss, Stent-In-Stent Entrapment, and Subsequent Surgical Extraction

Background: Percutaneous coronary intervention of calcified coronary lesions is fraught with short-term and long-term risks. Judicious use of adjunct intracoronary imaging and lesion modification techniques minimizes adverse outcomes. We present an exceedingly rare case of stent loss, stent-in-stent entrapment, and eventual surgical revascularization after failed percutaneous coronary intervention. Case Presentation: A 59-year-old man with a history of obstructive coronary artery disease and prior percutaneous coronary intervention presented with accelerating angina and exertional dyspnea. Elective angiography revealed a heavily calcified right coronary artery with significant stenoses. He underwent elective percutaneous coronary intervention without lesion interrogation or preparation, complicated by distal stent under-expansion and entrapment within the proximal stent. He was subsequently transferred to a tertiary referral center to undergo heart-team approach for salvage and eventual revascularization. Surgical foreign body removal and on-pump coronary artery bypass grafting were successful under trans-esophageal echocardiographic guidance. Remnants of the original stent were left in place to prevent collateral flow and mitigate the risk of graft failure. The patient was symptom-free with preserved left ventricular ejection fraction one year after surgery. Conclusions: Current guidelines recommend thorough interrogation of calcified lesions (intracoronary imaging, functional testing), and, if indicated, adequate lesion preparation (lithotripsy, atherectomy, etc) prior to percutaneous coronary intervention. This case demonstrates the critical importance of a multidisciplinary heart-team approach in preventing complications, but also in salvaging them after failed percutaneous coronary intervention.