Late coronary ostial stent fracture and embolism causing an acute thrombotic occlusion of the carotid artery with cerebral infarction.

A 56-year-old woman presented 30 minutes after onset of a right arm paresis. The cardiovascular risk factors included high cholesterol levels and heavy smoking, leading to a posterior myocardial infarction 6 years earlier, with stenting of a subtotal right coronary artery (RCA) ostial stenosis (3×13 mm bare metal stent). A symptomatic 70% RCA ostial restenosis, 9 months after initial percutaneous transluminal coronary angioplasty, led to the deployment of a 3×18 mm Cypher stent (Cordis,Warren, New Jersey) within the former RCA stent, postdilated (3.5×10 mm and 4.0×20 mm balloon, 25 bar) with a satisfactory result, the proximal end of the drug eluting stent (DES) protruding into the aorta (Figure 1A).The carotid arteries were known to be free of stenotic lesions. After the admission in the neurology department, a computed tomography examination revealed a significant reduction in the perfusion of the right brain hemisphere without cerebral infarction, the subsequent computed tomography-angiography showed a thrombotic occlusion of the extracranial right internal carotid artery, with a patent intracranial segment (Figure 1B). The cause of the occlusion was not recognized. An ultrasound examination confirmed the presence of recent thrombotic material occluding the carotid artery. Because of the recent onset of the symptoms and lack of cerebral infarction, we decided that immediate surgery was the best course of action. The patient underwent a standard carotid artery thrombectomy under general anesthesia. After the arteriotomy of the internal carotid artery, the thrombotic nature of the occlusion was evident. During the successful thrombectomy with a 2F, 4 mm Fogarty catheter we came upon a stent embedded in thrombus (Figure 2A–2C). With strong backflow from the internal carotid artery, we closed the arteriotomy with a vein patch under shunt protection. The right internal carotid artery was patent without evidence of intracranial embolism. The patient