Late stent thrombosis as a complication of T and small protrusion bifurcation stenting: a case report

BACKGROUND: A case of stent thrombosis as a complication of coronary bifurcation stenting is described. We review potential complications of bifurcation stenting and established guidelines. CASE SUMMARY: A 64-year-old man presented with a non-ST segment elevation myocardial infarction. High-sensitivity troponin I peaked at 99 000 ng/L (normal <5). He previously had coronary stenting for stable angina when residing in another country 2 years previously. Coronary angiography revealed no significant stenosis with TIMI 3 flow in all vessels. Cardiac magnetic resonance imaging demonstrated a left anterior descending artery (LAD) territory regional motion abnormality, late gadolinium enhancement consistent with recent infarction, and a left ventricular apical thrombus. Repeat angiography and intravascular ultrasound (IVUS) confirmed bifurcation stenting at the junction of the LAD and second diagonal (D2) with protrusion of several millimetres of the uncrushed proximal segment of the D2 stent in the LAD vessel lumen. There was under-expansion of the LAD stent in the mid-vessel and stent malapposition in the proximal LAD, extending into the distal left main stem coronary artery and involving the ostium of the left circumflex coronary artery. Percutaneous balloon angioplasty was performed along the length of the stent, including an internal crush of the D2 stent. Coronary angiography confirmed a uniform expansion of the stented segments and TIMI 3 flow. Final IVUS confirmed full stent expansion and apposition. DISCUSSION: This case highlights the importance of provisional stenting as a default strategy and familiarity with procedural steps in bifurcation stenting. Furthermore, it emphasizes the benefit of intravascular imaging for lesion characterization and stent optimization.