European Journal of Cardiovascular Medicine

Percutaneous coronary intervention (PCI) involving totally Occluded and tortuous coronary arteries poses significant technical challenges and risks. One such complication is stent fracture, a recognized cause of in-stent restenosis following drug-eluting stent (DES) implantation. Although relatively uncommon, stent fractures are associated with serious adverse outcomes such as stent thrombosis, coronary aneurysm formation, and in rare cases, coronary perforation.

Several case reports highlight the devastating consequences that can arise from stent fractures. Harish et al. described the development of a coronary aneurysm at a stent fracture site in the left anterior descending artery (LAD) two years post- DES implantation, while Choi et al. reported a massive 4-cm coronary aneurysm in the mid-right coronary artery (RCA) following a stent fracture, resulting in cardiac tamponade within three months. Hoshi et al. detailed a fatal case involving a pseudoaneurysm at the RCA ostium secondary to stent fracture, culminating in cardiopulmonary arrest shortly after diagnosis. 1

Management strategies for complications arising from stent fractures vary depending on the severity and clinical presentation. Conservative management with careful monitoring is recommended in stable cases without major bleeding, while more aggressive interventions, such as implantation of covered stents or surgical repair, may be required in cases of worsening hemorrhage or risk of vessel rupture.1–3,

In the present case, a stent fracture occurred immediately after the removal of the balloon and guidewire from a previously occluded and tortuous RCA. Notably, a myocardial bridge, previously masked by total occlusion, became evident after stent deployment. Prompt recognition and intervention were critical to prevent adverse events such as stent thrombosis. An immediate strategy was adopted involving careful re-crossing of the fractured segment, sequential balloon dilations, and deployment of an overlapping drug-eluting stent, resulting in a successful outcome with restored TIMI III flow and no procedural complications.

A 70-year-old male smoker presented with complaints of a sudden onset compressive type of compressive-type central chest pain, associated with sweating and radiation to the left shoulder since last 1 hour. It was not associated with nausea, vomiting, breathlessness, or syncope and there were no other conventional risk factors of coronary artery disease (CAD). In the emergency room, he was anxious with a pulse rate of 54 beats/min and a blood pressure of 130/80 mmHg. The neck veins were not distended. His room air oxygen saturation was 99%, with normal heart sounds and there were no murmurs or rales on auscultation.

An electrocardiogram (ECG) showed sinus rhythm, sinus bradycardia with ST-segment elevation in lead II, III, aVF with reciprocal changes in leads I and aVL, which suggested acute inferior ST-elevation myocardial infarction (STEMI). Transthoracic echocardiogram showed hypokinesia of the basal and mid-inferior wall with mild mitral regurgitation and mildly impaired left ventricular ejection fraction (LVEF – 45%). He was promptly transferred to the catheterization laboratory after loading with 325 mg of aspirin, 180 mg of ticagrelor, and 80 mg of atorvastatin. Coronary angiogram via right femoral access showed total thrombotic occlusion at the proximal right coronary artery (RCA) with minimal disease of the left coronary artery and its branches. the patient was taken immediately for primary percutaneous coronary intervention (PCI) after explaining potential risks and safeguards of the procedure.

Figure 1: ECG of the patient on Admission

PCI was done through a 7F femoral artery sheath. RCA was engaged using a 7F JR 3.5 guiding catheter. Repeat acquisition was done after crossing the RCA lesion with a 0.014″ Hi-Torque Balance Middleweight™ (Abbott Vascular). Thrombus aspiration was done using a 6F X-change aspiration catheter (Purple Microport Cardiovascular Private Limited) to achieve TIMI II Flow. Severe (90%) lesion was present in the proximal segment of RCA, which was the culprit for STEMI. The lesion was pre-dilated using NC TREK™ RX - Coronary Balloon Dilatation Catheter (Abbott Vascular) 2.00 mm x 8 mm, single inflation up to 16 ATM. A 3.5×28 mm Promus PREMIER™ Everolimus-Eluting Platinum Chromium Coronary Stent (Boston Scientific) was deployed in the proximal RCA segment and inflated up to 11 ATM. The suitable stent diameter was estimated by comparing the proximal healthy part of the artery with the diameter of the guiding catheter. The Stent was post dilated with NC TREK™ RX 3.5 mm x 8 mm Balloon and inflated up to 16 ATM to achieve good stent opposition with good final angiographic results with TIMI flow III.

Upon removal of the balloon and guidewire from the RCA an unexpected and rather unique occurrence was observed, there was a sudden fracture of the distal end of the previously deployed well opposed stent, along with the evidence of a strong myocardial bridge in the proximal RCA, which had not been apparent earlier due to total vessel occlusion and tortuosity.

An immediate decision was made to address the stent fracture to prevent complications such as acute stent thrombosis. With much difficulty the same BMW guidewire was reinserted through the fractured segment and an attempt was made to cross the fractured stent with a 3.0 × 8 mm NC Trek balloon, but was unsuccessful due to the severity of the fracture at the distal end. Subsequently, a smaller 2.0 × 8 mm NC Trek balloon was carefully advanced across the fractured segment and inflated at 16 ATM to create a pathway for a larger Balloon and stent. Following this, the distal stent segment was predilated further with a 3.0 × 8 mm NC Trek balloon. A new drug-eluting stent, 3.5 × 38 mm Promus PREMIER™ was then crossed through the previously implanted stent and successfully deployed in the proximal RCA at 11 ATM. The stent was then post-dilated using a 3.5 × 8 mm NC TREK™ Balloon at 16 ATM. The final angiographic result demonstrated adequate stent expansion with TIMI III flow, and no procedural complications were encountered.