When an 8‐mm Coronary Artery Has No Appropriate Stent: Bailout PCI and Dual‐Balloon Optimization in Giant Right Coronary Artery Ectasia

Giant coronary artery ectasia with acute thrombotic occlusion presents a difficult interventional challenge because of the large thrombus burden, impaired washout, distal embolization, and lack of appropriately sized coronary stents. A 69-year-old woman presented with inferior ST-segment elevation myocardial infarction caused by thrombotic subtotal occlusion of an approximately 8-mm dominant right coronary artery (RCA). Primary percutaneous coronary intervention was complicated by recurrent thrombotic no-reflow despite sequential balloon angioplasty, selective aspiration thrombectomy, large-lumen aspiration, and intracoronary antiplatelet and fibrinolytic therapy. Intravascular ultrasound (IVUS) demonstrated extensive residual thrombus and a true vessel diameter substantially larger than available coronary stent platforms. Because balloon deflation repeatedly resulted in vessel collapse with persistent TIMI 0-1 flow and hemodynamic instability, a 5.0-mm drug-eluting stent was implanted as a bailout scaffold. Persistent proximal malapposition was subsequently improved using simultaneous inflation of 6.0- and 4.0-mm noncompliant balloons, restoring TIMI 3 flow. Three days later, the patient developed a large left cerebellar intracranial hemorrhage requiring surgical evacuation and external ventricular drainage. Antithrombotic therapy was withheld and subsequently reintroduced in a staged, imaging-guided manner. Follow-up angiography and IVUS demonstrated preserved TIMI 3 flow, satisfactory stent expansion and apposition, and residual non-flow-limiting thrombotic material. This case highlights the limitations of conventional coronary stenting in giant ectatic arteries and the role of IVUS in guiding bailout stent optimization and follow-up assessment. It also emphasizes the need to balance stent thrombosis against recurrent intracranial bleeding. A 69-year-old woman presented with inferior ST-segment elevation myocardial infarction caused by thrombotic subtotal occlusion of an approximately 8-mm dominant right coronary artery (RCA). Primary percutaneous coronary intervention was complicated by recurrent thrombotic no-reflow despite sequential balloon angioplasty, selective aspiration thrombectomy, large-lumen aspiration, and intracoronary antiplatelet and fibrinolytic therapy. Intravascular ultrasound (IVUS) demonstrated extensive residual thrombus and a true vessel diameter substantially larger than available coronary stent platforms. Because balloon deflation repeatedly resulted in vessel collapse with persistent TIMI 0-1 flow and hemodynamic instability, a 5.0-mm drug-eluting stent was implanted as a bailout scaffold. Persistent proximal malapposition was subsequently improved using simultaneous inflation of 6.0- and 4.0-mm noncompliant balloons. TIMI 3 flow was restored. Three days later, the patient developed a large left cerebellar intracranial hemorrhage with fourth-ventricular compression requiring suboccipital craniectomy, hematoma evacuation, and external ventricular drainage. Antithrombotic therapy was withheld and subsequently reintroduced in a staged, imaging-guided manner. Follow-up angiography and IVUS demonstrated preserved TIMI 3 flow, satisfactory stent expansion and apposition, and residual non-flow-limiting thrombotic material.