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 balloon 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, cutting/scoring balloon) prior to percutaneous coronary intervention. This case highlights the technical reasons for this complication, discussion on various percutaneous retrieval techniques, and the critical importance of a multidisciplinary heart-team approach in preventing complications, but also in salvaging them after failed percutaneous coronary intervention.