Coronary stent loss is a rare but potentially catastrophic complication of percutaneous coronary intervention (PCI), particularly during complex procedures involving calcified lesions and bifurcations. We report the case of a 74-year-old man undergoing PCI of a subacutely occluded proximal left anterior descending artery, complicated by stent dislodgement following an involuntary deep inspiration by the patient. The stent became partially detached from the delivery balloon and was successfully moved into the radial artery while remaining over the guidewire. A stepwise bailout strategy allowed safe completion of the coronary intervention via secondary access, followed by successful snaring and retrieval of the lost stent. This case highlights the importance of maintaining wire position, procedural patience, and structured problem-solving in managing rare but high-risk intraprocedural complications.
Case Presentation
A 74-year-old man with no major comorbidities was admitted with non–ST-segment elevation myocardial infarction. High-sensitivity troponin T peaked at 1,735 ng/L. Transthoracic echocardiography showed moderate left ventricular systolic dysfunction (ejection fraction 41%) with akinesia of the apical segments.
Coronary angiography revealed a subacute occlusion of the proximal left anterior descending artery (LAD), with collateral flow from the right coronary artery. Given the patient’s asymptomatic status at the time of the procedure and the anticipated complexity of revascularization involving the left main bifurcation, the case was discussed by the multidisciplinary heart team. After Heart Team discussion, both CABG and PCI were considered feasible. The patient had a low predicted surgical risk (EuroSCORE II 1.61%) and an intermediate anatomical complexity (SYNTAX score I 24.5). SYNTAX score II suggested comparable 4-year mortality estimates between CABG and PCI (9.1% vs 11.2%). Following shared decision-making that included procedural risk, expected durability, and the patient’s preference, PCI was pursued.
Procedural Details
Because of the absence of antegrade flow and homolateral collateral filling, dual access was obtained to enable adequate visualization of the occlusion course and accurate assessment of the distal cap. Femoral access was considered; however, a dual radial approach was selected in accordance with local practice and the patient’s risk profile ( Figure 1 ). Diagnostic right coronary angiography was performed via left radial access using a 6 Fr JR4 catheter, while PCI was performed via right radial access using a 7 Fr EBU 3.75 guiding catheter. Lesion crossing was achieved with a microcatheter-assisted strategy using a tapered, polymer-jacketed guidewire. Initial balloon dilatation and thromboaspiration were performed, followed by intravascular ultrasound, which confirmed a crossable but severely calcified lesion with a high calcium burden ( Figure 2 ).
( A-B ) Dual injection pre-PCI set up angiograms.
Severe calcification on IVUS imaging.
A balloon-based plaque modification strategy was selected, including noncompliant balloon dilatation and intravascular lithotripsy (IVL). After adequate lesion preparation, a 3.0 × 32 mm drug-eluting stent was deployed in the mid-LAD. Proximal optimization technique, distal rewiring, and kissing balloon inflation at the LAD–diagonal bifurcation were subsequently performed.
Complication
During positioning of a second, more proximal stent at the left main bifurcation, the patient took a sudden deep breath. This resulted in inadvertent guiding catheter disengagement with partial withdrawal into the ascending aorta. The stent became partially dislodged from the delivery balloon while remaining on the guidewire, with its proximal edge still inside the guiding catheter ( Figure 3 ) . In the absence of stable guide support and with partial stent detachment from the balloon, further advancement and attempted deployment were deemed unsafe because of inadequate guide–coronary alignment and the risk of stent deformation, loss of wire position, and uncontrolled stent embolization. A second (parallel) guidewire was advanced, and a 2.75 mm balloon was used to trap the stent within the guiding catheter ( Figure 3 ). This maneuver allowed the stent to be brought back into the radial artery, where it detached from the guiding catheter while remaining over the original wire.
