Author + information
- Received March 8, 2018
- Accepted March 20, 2018
- Published online September 3, 2018.
- Ajay S. Chaurasia, MD, DM,
- Jaywant M. Nawale, MD, DM, DNB,
- Digvijay D. Nalawade, MD, DM∗ ( and )
- Nikhil A. Borikar, MD, DM, DNB
- ↵∗Address for correspondence:
Dr. Digvijay D. Nalawade, 18-ICCU, Department of Cardiology, Ground Floor, OPD Building, Nair Hospital, Mumbai Central, Mumbai-400008, Maharashtra, India.
A 59-year-old man with diabetes presented with exertional dyspnea and angina for 3 months. He had a history of inferior wall myocardial infarction 9 months previously, with percutaneous intervention of an 80% tubular lesion of the mid-right coronary artery (RCA) with a 3.5 × 28 mm drug eluting stent (PROMUS Element, Boston Scientific, Natick, Massachusetts) (Figures 1A and 1B). Six months previously, he was admitted to another hospital with chest pain following blunt chest trauma and was diagnosed with non–ST-segment elevation myocardial infarction. He was initially stabilized medically, and later coronary angiography revealed 100% in-stent thrombosis with no distal flow (Figure 1C). He was advised to undergo reintervention but refused and continued medical therapy.
At our institution, 2-dimensional echocardiography revealed an unusual echogenic structure in the right atrioventricular groove in the apical 4-chamber view (Figure 2A). The patient was suspected to have stent infection or abscess. Cardiac magnetic resonance imaging was done and showed low signal area reflecting the stent, surrounded by abnormal, ill-defined soft tissue extending along the atrioventricular groove in the course of the RCA, suggestive of either stent infection or stent migration with pericardial thickening (Figure 2B). However, the patient had no history of fever, his blood counts were normal, and later his blood cultures revealed no growth.
Further evaluation with cardiac CT (Figures 2C, 2D, and 3A to 3D) revealed nonopacification of a 1.5-cm segment of the mid-RCA beyond the first genu. The stent in the mid-RCA appeared to have migrated or displaced across the wall of the RCA and was now located in the right atrioventricular groove with complete in-stent thrombosis. Irregular perifocal localized pericardial fluid collection and soft tissue thickening were seen surrounding it. The distal RCA was normal in course and caliber. Other coronary arteries revealed minor plaques, with anomalous origin of the left circumflex coronary artery. Coronary angiography also revealed proximal in-stent total occlusion with antegrade filling of the distal RCA through intracoronary collateral vessels, with loss of normal alignment of the stent along the vessel course, indicating stent migration (Figure 1D).
No viable tissue in the RCA territory was seen on cardiac magnetic resonance imaging, and hence further intervention to salvage the RCA supply was deferred. Because of late presentation, the exact cause of stent migration could not be ascertained. However, 6 months before presenting to our facility, the patient had experienced blunt chest trauma, which although rare is known to cause coronary artery dissection with acute myocardial infarction or coronary perforation with tamponade (1,2). The cause of the unusual stent migration in our case can be hypothesized to be medial wall injury with dissection secondary to blunt chest trauma followed by subsequent complications such as slow vessel perforation with secondary stent thrombosis (3). Stent thrombosis might have prevented the formation of hemopericardium that usually occurs after vessel rupture.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 8, 2018.
- Accepted March 20, 2018.
- 2018 American College of Cardiology Foundation
- Abdolrahimi S.A.,
- Sanati H.R.,
- Ansari-Ramandi M.M.,
- Heris S.O.,
- Maadani M.
- Bharati A.,
- Merchant S.,
- Suvarna T.,
- Parashar N.