Erroneously deployed, old ostial RCA stent, overhanging in the aorta with symptomatic ostial severe ISR, snared, stented and successfully averted single vessel bypass

Abstract

We present a complex case of a 77-year-old high-surgical-risk patient with refractory angina due to severe in-stent restenosis (ISR) of a malpositioned right coronary artery (RCA) ostial stent protruding into the Aorta. Despite prior PCIs, including overlapping drug-eluting stents (DES), progressive ISR led to debilitating symptoms. Diagnostic imaging revealed an 8–10 mm aortic overhang of the RCA stent, complicating catheter engagement. A multidisciplinary team pursued percutaneous management to avoid high-risk CABG. Using femoral access and a temporary pacemaker, a malpositioned stent was successfully snared and removed. Subsequent OCT-guided PCI involved distal 3.0 × 32 mm and ostial 3.5 × 16 mm PROMUS DES deployment, optimized with intravascular imaging. The procedure restored TIMI III flow, resolving symptoms without complications. This case demonstrates the successful percutaneous retrieval and imaging-guided PCI for aortic-ostial ISR, highlighting the importance of careful planning, advanced interventional techniques, and a multidisciplinary approach to minimize the need for invasive surgery in high-risk patients.