“Double Trouble” in TAVI: Management of a Complex Case Characterized by Left Main Coronary Artery Obstruction and Stent Migration

Coronary obstruction following transcatheter aortic valve implantation (TAVI) is a rare but life-threatening complication classically associated with a low coronary ostial height and narrow sinuses of Valsalva. However, additional anatomical factors, such as bulky calcification, may also contribute to its occurrence. We report the case of a 75-year-old woman with severe symptomatic aortic stenosis who underwent TAVI despite favorable multidetector computed tomography parameters, including an adequate left main coronary artery height and appropriate sinus of Valsalva dimensions. However, prominent bulky calcification was present in the aortic valve. Following implantation of a balloon-expandable valve, acute left main coronary artery obstruction developed, resulting in hemodynamic instability. This complication was successfully managed with emergency percutaneous coronary intervention and ostial stenting. Shortly thereafter, a second complication occurred because of early stent migration and deformation, which was effectively treated with balloon dilation and deployment of a second overlapping stent. This case demonstrates that coronary obstruction may occur in the presence of bulky calcification, even when conventional predictors indicate a low-risk profile. Furthermore, it highlights the complexity of percutaneous interventions in such patients, emphasizing their high susceptibility to complications and the need for meticulous procedural caution.

Keywords: Bulky calcification, coronary obstruction, stent migration, transcatheter aortic valve implantation.