Unintended distal embolisation of a drug-coated balloon during percutaneous coronary intervention: when is leaving the device in situ feasible?

Background: Balloon angioplasty can lead to multiple complications, such as myocardial perforation and dissection of coronary arteries. Device dislodgment during percutaneous coronary intervention (PCI) is a rare but potentially life-threatening complication. Case description: We report on a 67-year-old woman presenting with acute coronary syndrome due to in-stent restenosis of the left circumflex artery, treated with a drug-coated balloon (DCB) following lesion preparation. During DCB retrieval resistance was encountered, and angiography revealed separation of the balloon from its shaft with distal embolisation. Despite this, thrombolysis in myocardial infarction (TIMI) flow grade 3 was preserved. After multidisciplinary discussion, conservative management was chosen due to the distal location of the embolised device and risks associated with retrieval. Final angiography showed no procedural complication, and at 12-month follow-up, the patient remained asymptomatic without ischaemic or device-related events. Conclusion: This example shows that in certain patients with intact coronary flow and no procedural complications, conservative therapy of distal DCB embolisation might be a safe and feasible strategy. LEARNING POINTS: This case highlights that, in selected patients, leaving an embolised device in situ may be a safe and feasible strategy when distal flow is preserved and procedure risks outweigh benefits of retrieval.