Right Coronary Artery Perforation with Subsequent Graft Stent Embolization to the Left Main Coronary Artery - It Never Rains but It Pours!

Sep 28, 2026

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Letter to the Editor describing a 72-year-old female with acute coronary syndrome who underwent PCI after coronary angiography showed critical distal RCA stenosis with severe tortuosity and calcification. During predilation and DES implantation for the PDA culprit lesion, an Ellis type 3 distal coronary rupture occurred, requiring balloon-induced coronary occlusion and additional measures including protamine. Despite attempts to implant a graft stent at the bifurcation level, the stent embolized into the left main coronary artery, prompting emergency surgery. The report emphasizes sequential rare complications and the need for timely surgical backup, along with risk mitigation strategies during high-risk PCI.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Letter to the Editor

Case presentation during PCI

Management of perforation and stent embolization

Clinical implications and risk mitigation

DOI: 10.4274/MMJ.galenos.2025.89021 Medeni Med J 2025;40:278-279 Letter to the Editor Right Coronary Artery Perforation with Subsequent Graft Stent Embolization to the Left Main Coronary Artery: It Never Rains but It Pours! Sağ Koroner Arter Perforasyonunu Takiben Sol Ana Koroner Artere Greft Stent Embolizasyonu: Yağmur Yağmaz ama Yağınca Sağanak Yağar! Efe YILMAZ, Furkan KARAHAN, Çağlar KAYA, Kenan YALTA Trakya University Faculty of Medicine, Department of Cardiology, Edirne, Türkiye *This study was presented as a poster at the 2024 National Cardiology Congress. | Keywords: Coronary perforation, percutaneous coronary intervention, stent embolization Anahtar kelimeler: Koroner perforasyon, perkütan koroner girişim, stent embolizasyonu | | | --- | --- | | Dear Editor,
A 72-year-old female patient was hospitalized with acute coronary syndrome. Coronary angiogram (CAG) demonstrated a critical stenosis in the distal right coronary artery (RCA) [posterior descending artery,(PDA)]; the artery was severely tortuous and calcified. The Amplatz 1 guiding catheter was engaged into the RCA. The PDA and posterolateral artery branches were pruned The culprit lesion in the PDA was then predilated with 1.5×12-mm and 2.0×10-mm compliant balloons, respectively. Finally, a 2.5×23-mm DES was implanted in the predilated stenotic segment. However, repeat images demonstrated an Ellis type 3 coronary rupture distal to the PDA at the level of distal bifurcation point. Subsequently, coronary obstruction was induced using a 2.75×10 mm non-compliant (NC) balloon for 3 minutes. Because the perforation persisted on repeat CAG images, coronary occlusion was performed using 2.0 × 6-mm NC and 2. 5×10-mm NC balloons, inflated three consecutive times, each for more than 10 minutes. Thereafter, the extra-stiff guidewire was exchanged for a | floppy guidewire over a microcatheter to prevent further guidewire-induced perforation. Intravenous protamine was also administered. Due to the failue of all the abovementioned attempts, we decided to implant a graft stentin the PDA at the level of bifurcation point. However, the stent graft could not be advanced beyond the mid-RCA. We retrieved the balloon-stent system, however, we were not able to discern any stent material over the balloon. Thereafter, we inflated a 1.0×10 mm compliant balloon distal to the system and pulled the system back. However, the stent material remained loose. To our consternation, we were able to identify the stent material in the left main coronary artery (LMCA) CAG images. The patient was transferred for emergency surgery due to persistent coronary perforation and dislodged stent material in the LMCA.
The primary focus of this report is the sequential occurrence of two severe coronary complications ina single patient. This report also underscores that a timely surgical backup is essential during PCI. Although coronary perforations and stent dislodgement are quite | Address for Correspondence: E. Yilmaz, Trakya University Faculty of Medicine, Department of Cardiology, Edirne, Türkiye [E-mail:](E-mail: drefeyilmaz@gmail.com ORCID ID: orcid.org/0000-0003-2976-3063)[ drefeyilmaz@gmail.com](E-mail: drefeyilmaz@gmail.com ORCID ID: orcid.org/0000-0003-2976-3063)[ ORCID ID:](E-mail: drefeyilmaz@gmail.com ORCID ID: orcid.org/0000-0003-2976-3063)[ orcid.org/0000-0003-2976-3063](E-mail: drefeyilmaz@gmail.com ORCID ID: orcid.org/0000-0003-2976-3063) Cite as: Yilmaz E, Karahan F, Kaya C, Yalta K. Right coronary artery perforation with subsequent graft stent embolizationto the left main coronary artery: it never rains but it pours! MedeniMed J. 2025;40:278-279 Received: 27.10.2025 Accepted: 31.10.2025 Published: 31.12.2025 Copyright© 2025 The Author. Published by Galenos Publishing House on behalf of Istanbul Medeniyet University Faculty of Medicine. This is an open access article under the Creative Commons AttributionNonCommercial 4.0 International (CC BY-NC 4 . 0) L

FAQs

Why is surgical backup considered essential in PCI?

Because severe coronary perforation and stent dislodgement can occur even though they are rare, timely surgical backup is necessary when percutaneous attempts fail.

Sep 28, 2026

Uploaded by kopisore