Stent Embolization in Spontaneous Coronary Artery Dissection and Its Deployment at the Right Radial Artery

Spontaneous coronary artery dissection (SCAD) is an unusual but important cause of acute coronary syndrome and is often underdiagnosed. The first clue to the diagnosis is the angiographic appearance of the lesion, and, in certain cases, intravascular imaging is needed to confirm it. Conservative management is the preferred treatment strategy for the majority of cases. However, revascularization is needed in the presence of high-risk features, including hemodynamic instability, ongoing ischemia, and left main dissection. We report a case of a 43-year-old man who presented with acute inferior wall myocardial infarction. Angiogram revealed SCAD of the right coronary artery (RCA). In view of ongoing chest pain, we proceeded with direct stenting. However, during the stent delivery, the stent got embolized and laid unexpanded in the proximal RCA. The stent was successfully retrieved and was deployed at the right radial artery. Subsequently, after the troubleshoot, we again secured wire access across the RCA, and this time after pre-dilatation, successful stenting across the SCAD segment was achieved. Percutaneous coronary intervention (PCI) in SCAD is technically challenging with lower success and higher complication rates compared to atherosclerotic disease. Stent embolization is a potential complication during PCI of SCAD and to the best of our knowledge has never been reported before. Though, in general, the SCAD lesion is soft and one may proceed with direct stenting with long stents, occasionally adequate pre-dilatation may be necessary in order to facilitate the smooth passage of stent across the lesion. Though stent embolization in SCAD is a rare event, the operator must be aware of such a possibility and the potential bailout strategies if faced with such a scenario.