Abstract
Delayed perforation of the coronary artery and extraluminal migration of coronary stent is a rare phenomenon. We report a case in which the stent was documented to perforate the coronary artery at least 1 year after the intervention and migrated within the pericardium without any symptom. (Level of Difficulty: Intermediate.)
Key Words: right coronary artery, STEMI, stent graft
Abbreviations and Acronyms: RCA, right coronary artery
Central Illustration
A 58-year-old woman with a history of recent inferior-wall ST-segment elevation myocardial infarction and 100% obstruction at the middle part of the right coronary artery (RCA) underwent percutaneous coronary intervention. After initial placement, the guidewire was found to be in a false passage (Figure 1A). Subsequently, the guidewire was advanced into the true lumen of the artery (Figure 1A), but a grade 2 coronary artery perforation was noted (Figure 1B, Video 1) and a 3 × 30 polytetrafluoroethylene-coated balloon-expandable stent–graft (Prograft, Vascular Concept, Bengaluru, Karnataka, India) was implanted (Figure 1C). She presented with angina on exertion, Class II. In view of previous history of myocardial infarction and coronary revascularization, she underwent the coronary angiography. One year after the procedure, coronary angiography demonstrated 100% in-stent restenosis in the RCA stent (Figure 1D, Video 2) and 70% obstruction in the proximal left anterior descending artery. Coronary artery bypass graft surgery was recommended, but she opted for medical follow-up. Two years after the index procedure, coronary angiography before noncardiac surgery RCA demonstrated 100% obstruction of the middle part of the RCA with migration of the coronary stent out of the RCA contour (Figure 1E, Video 3) and opacification of the distal part of the vessel by collaterals. A dedicated computed tomographic coronary angiography scan revealed that the stent had perforated the RCA, had migrated across the wall to partially lie in the pericardial sac, and was surrounded by pericardial adhesion (Figure 1F).
Figure 1.
Delayed Extraluminal Migration of Intracoronary Stent Into Pericardial Space
(A) Coronary guidewire (blue arrow) is outside the true arterial lumen (green arrow) and subsequently, the guidewire was advanced in the true lumen (blue arrow). (B) Extravasation of contrast agent (yellow arrow) from coronary artery perforation. (C) Final result after implantation of the stent-graft (yellow arrow). (D) Angiogram showing 100% obstruction within the stent (yellow arrow). The stent appears to be within the coronary artery. (E) Angiography demonstrating migration of stent (yellow arrow) outside the contour of the right coronary artery (RCA) (green arrow). (F) Computed tomographic coronary angiography shows partial migration of the stent (yellow arrow) into the pericardial space.
Although migration of an intracoronary stent into pericardial space is reported in association with stent fracture (1,2) or chest trauma (3), the phenomenon was spontaneous in our patient. Identification of the exact cause of stent migration is difficult without intracoronary imaging studies. However, repeated friction of the relatively rigid stent-graft against the physiological distal curve of the right coronary artery from constant cardiac motion may be one possible mechanism. Perforation of the coronary artery into the pericardial cavity is usually catastrophic (2), but in our case, the patient was asymptomatic because of prior occlusion of the proximal arterial segment.
Funding Support And Author Disclosures
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
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Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Coronary angiography during index procedure shows extravasation of contrast agent from proximal part of diseased segment.
Angiogram shows 100% obstruction within the stent. The stent appears to be within the coronary artery
Angiography demonstrates migration of stent outside the contour of the right coronary artery
References
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Supplementary Materials
Coronary angiography during index procedure shows extravasation of contrast agent from proximal part of diseased segment.
Angiogram shows 100% obstruction within the stent. The stent appears to be within the coronary artery
Angiography demonstrates migration of stent outside the contour of the right coronary artery