Embolization Of Fragments Research Articles

Balloon rupture during transcatheter aortic valve replacement.

A distinctive complication with balloon-expandable (BE) THV platforms such as the Edwards Sapien (Edwards Lifescience) is the possibility of balloon rupture during THV deployment. Balloon rupture is a rare occurrence that can result in stroke due to fragment embolism, incomplete THV expansion, and/or vascular injury upon retrieval of the balloon. Careful evaluation of preoperative computed tomography is essential to identify high-risk cases. While annular and left ventricular outflow tract (LVOT) calcification are widely acknowledged as common risks for balloon injury, it's essential to note that balloon injury can manifest at various anatomical sites. In this review, we discuss the mechanism behind balloon rupture, methods to identify cases at a heightened risk of balloon injury, approaches to mitigate the risk of rupture, and percutaneous retrieval strategies.

Use of a funneled sheath for embolic protection during removal of thrombosed Simon Nitinol filters.

Inferior vena cava (IVC) filters should be removed when no longer needed, given their association with complications such as thrombosis of the IVC and lower extremities, fracture, migration, and growth into adjacent structures. While this is generally straightforward in the setting of retrievable filters, permanent filters present more of a challenge. In fact, many operators will not attempt to do so for fear of intraprocedural complications, among them, filter fracture and fragment embolization. Despite this, leaving the filters in situ places patients at risk of the complications described above. Here, the authors illustrate a novel technique for retrieving permanent filters using a funneled sheath to protect against embolization.

P12 COMPLEX LEAD EXTRACTION: A PERCUTANEOUS MULTIDISCIPLINARY APPROACH

Abstract Introduction The infection represents one of the most serious complications of implantable cardiac systems (ICDs and PMs) and is associated with increased mortality and significant expenditure of financial resources. The incidence, which ranges from 0.6 to 3.4%, depends by the patient characteristics, the type of implanted system, and from other factors related to the procedure itself. When diagnosed, it is recommended extraction of the system. A 77–year–old patient, hypertensive, obese, former tobacco user, suffering from chronic ischemic heart disease and carrier of bicameral PM since 2019 for BAV grade III. In June 2022 decubitus of the PM pocket. Considering the negativity of coltural tests and the absence of fever, it was decided to use a conservative approach by doing a curettage of the pocket and by repositioning the device at the submuscular level. After about a month, a reappearance of decubitus with exposure of the PM case occurred, therefore, a complete extraction of the leads and removal of the device was performed. The surgery, performed under general anaesthesia, was complicated by the fracture of both leads at the level of the anonymous vein. With the introduction of dedicated ligature through the right femoral vein, it was possible to successfully extract the ventricular lead stump. During the recapture of the atrial stump, a migration of the stump into the right ventricle and then into the pulmonary circulation to a terminal branch of the right pulmonary artery occurred. The recovery of such stump was possible with the help of interventional radiologists and through the use of a dedicated material (“Gooseneck ligature catheter”). Subsequent implantation of temporary PM by the right jugular given the absence of underlying spontaneous rhythm. Conclusions CIED extraction surgery is burdened with a high risk of complications even serious ones, including lead rupture and distal fragment embolization. A multidisciplinary approach with shared choices and techniques allowed the resolution percutaneous resolution of a complex picture.

Grasp-and-Fold Technique for Complex Inferior Vena Cava Filter Retrieval

This study evaluated the use of the grasp-and-fold technique for complex forceps retrieval of inferior vena cava (IVC) filters. A retrospective study of 14 patients (12 women and 2 men) who had either deeply tip-embedded or severely distorted IVC filters was performed at a single institution over 10 years. In this technique, endobronchial forceps were used to fold the filter in half to remove it through the sheath because the filter tip could not be accessed by dissection. The grasp-and-fold technique successfully removed all 14 filters. One patient had retained filter struts, which were present before the procedure. One mild and 5 moderate adverse events (AEs), including fracture fragment embolization requiring retrieval and self-limited IVC extravasation, occurred. No severe AEs occurred. In this small patient cohort, the grasp-and-fold forceps technique successfully retrieved deeply tip-embedded or distorted IVC filters with inaccessible tips.

Abstract 10425: Needle Fragment Embolization Leading to Cardiac Tamponade

Background: Intravenous drug use (IVDU) may rarely result in needle embolism (1). We present a patient with history of active IVDU who was found to have pericardial effusion causing tamponade from needle fragment embolization. Case: 41-year-old female with history of active fentanyl use presented with pleuritic chest pain and dyspnea. EKG was consistent with acute pericarditis and she was started on colchicine and ibuprofen with symptomatic improvement. CT scan of the chest revealed a linear radiopaque structure along the inferior margin of pericardium (Figure 1). She had asymptomatic hypotension and echocardiogram showed moderate sized pericardial effusion with early signs of cardiac tamponade. She underwent median sternotomy and surgical evacuation of~400 ccs of hemopericardium and retrieval of intrapericardial needle fragment with anterior right atrial exit site. She did well post-operatively. She had previously presented 10-months prior with neck pain and lateral radiograph of the neck showed a needle fragment over the distal cervical trachea (Figure 2). Patient left against medical advice prior to treatment. Decision Making: Pericardiocentesis was deferred and surgical alternative was chosen after multidisciplinary discussion as she was asymptomatic and there was concern for ongoing bleeding from the needle exit site. Treatment options include conservative clinical monitoring in asymptomatic patients, pericardiocentesis/pericardial window, and surgical exploration of the mediastinal cavity (1). Conclusion: We describe a case of needle fragment embolization leading to cardiac tamponade requiring surgical evacuation and retrieval of foreign body.

Biomimetic Nanoplatelets to Target Delivery Hirudin for Site-Specific Photothermal/Photodynamic Thrombolysis and Preventing Venous Thrombus Formation.

Due to the high recurrence rate and mortality of venous thrombosis, there is an urgent need for research on antithrombotic strategies. Because of the short half-life, poor targeting capabilities, bleeding complications, and neurotoxic effects of conventional pharmacological thrombolysis methods, it is essential to develop an alternative strategy to noninvasive thrombolysis and decrease the recurrence rate of venous thrombosis. A platelet-mimetic porphyrin-based covalent organic framework-engineered melanin nanoplatform, to target delivery of hirudin to the vein thrombus site for noninvasive thrombolysis and effective anticoagulation, is first proposed. Owing to the thrombus-hosting properties of platelet membranes, the nanoplatform can target the thrombus site and then activate hyperthermia and reactive oxygen species for thrombolysis under near-infrared light irradiation. The photothermal therapy/photodynamic therapy combo can substantially improve the effectiveness (85.7%) of thrombolysis and prevent secondary embolism of larger fragments. Afterward, the highly loaded (97%) and slow-release hirudin (14 days) are effective in preventing the recurrence of blood clots without the danger of thrombocytopenia. The described biomimetic nanostructures offer a promising option for improving the efficacy of thrombolytic therapy and reducing the risk of bleeding complications in thrombus associated diseases.

Immediate and delayed complications of inferior vena cava filters

ObjectiveInferior vena cava (IVC) filter placement has increased dramatically in the past two decades. However, literature supporting the efficacy of these devices has been limited and controversial. In the present study, we have evaluated the predictors and rates of technical complications after IVC filter insertion in a large national database. MethodsThe Vascular Quality Initiative registry was explored (January 2013 to December 2020). Immediate complications were defined as venous injury requiring treatment, filter misplacement (failure to open, deployed >20 mm from intended site or in wrong vein, embolized to the heart), angulation >20°, and insertion site complications. Delayed complications were defined as migration, angulation >15°, fracture, caval and/or iliac thrombosis, filter thrombus, fragment embolization, and perforation. The Pearson χ2 test was used to compare the baseline characteristics between the patients who had developed immediate and/or delayed complications and those who had not. The predictors of these complications were evaluated using multivariable logistic regression, Cox proportional hazard regression, and Kaplan-Meier survival analysis. ResultsA total of 14,784 patients were included in the present analysis, with a median follow-up of 11 months (interquartile range, 4-16 months). The rate of immediate and delayed complications was 1.8% and 3.1%, respectively. Angulation (1.2%) was the most common immediate complication, and filter thrombosis (1.6%) was the most common delayed complication. Compared with the patients with no immediate complications, those with immediate complications were more likely to have had abnormal anatomy (6.0% vs 1.7%; P < .001) and a landing zone other than infrarenal (7.0% vs 4.2%; P = .02). Compared with their counterparts, those with delayed complications were less likely to have received statins (21.0% vs 29.5%; P = .006) and were more likely to have a family history of venous thromboembolism (8.0% vs 5.1%; P = .047). Logistic regression analysis revealed that renal vein visualization was associated a 50% reduction (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.27-0.92; P = .027) in the odds of immediate complications and female sex and abnormal anatomy were associated with a 41% (aOR, 1.41; 95% CI, 1.08-1.85; P = .013) and 244% (aOR, 3.44; 95% CI, 1.66-7.16; P < .001) increase in the odds of immediate complications, respectively. Immediate (P = .21) and delayed (P = .51) complications did not result in increased mortality. ConclusionsThe immediate and delayed IVC filter complication rates were 1.8% and 3.1%, respectively, but the occurrence of complications was not associated with increased mortality. Female sex was associated with an increase in the development of immediate complications. The incidence of immediate complications might be mitigated if advanced imaging were used for renal vein visualization before IVC filter deployment. Delayed complications might be avoided if IVC filter retrieval were performed in a timely fashion and institutional retrieval protocols were optimized.

Seek and you shall find—retrieval of a retained fractured intravenous cannula by Z-plasty incision: a case report

Peripheral venous cannulation is a common invasive procedure. Fracture of an intravenous cannula is rare and an under-reported complication of peripheral venous cannulation. Embolization of the intravenous fragment into the central venous system is potentially fatal. Urgent surgical retrieval, which is performed through a transverse or longitudinal incision, is the treatment of choice. We herein present the use of Z-plasty incision for the retrieval of a retained fractured peripheral intravenous cannula in a 61-year-old Nigerian man on hemodialysis for chronic kidney disease. The major benefits of this innovation are facilitation of access for exploration and prevention of joint contracture.

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Modeling Large Vessel Occlusion Stroke for the Evaluation of Endovascular Therapy According to Thrombus Composition.

More than 40% of endovascular therapy (EVT) fail to achieve complete reperfusion of the territory of the occluded artery in patients with acute ischemic stroke (AIS). Understanding factors influencing EVT could help overcome its limitations. Our objective was to study the impact of thrombus cell composition on EVT procedures, using a simulation system for modeling thrombus-induced large vessel occlusion (LVO) in flow conditions. In an open comparative trial, we analyzed the behavior of size-standardized platelet-rich and red blood cells (RBC)-rich thrombi during simulated stent retriever-mediated EVT procedures. Sixteen simulated EVT procedures were performed (8 RBC- vs. 8 platelet-rich thrombi). Platelet-rich thrombi were associated with a higher number of stent retriever passes (p = 0.03) and a longer procedure duration (p = 0.02) compared to RBC-rich thrombi. Conversely, RBC-rich thrombi released more embolic fragments than platelet-rich thrombi (p = 0.004). Both RBC-rich and platelet-rich thrombi underwent drastic compaction after being injected into the in vitro circulation model, and histologic analyses showed that these EVT-retrieved thrombi displayed features comparable to those previously observed in thrombi from patients with AIS patients having LVO, including a marked structural dichotomy between RBC- and platelet-rich areas. Our results show that the injection of in vitro-produced thrombi in artificial cerebrovascular arterial networks is suitable for testing recanalization efficacy and the risk of embolization of EVT devices and strategies in association with thrombus cell composition.

Bioresorbable magnesium scaffold in the treatment of simple coronary bifurcation lesions: The BIFSORB pilot II study.

ObjectivesTo evaluate the feasibility, safety, and healing response of a magnesium‐based bioresorbable scaffold (BRS) in the treatment of simple bifurcation lesions using the single stent provisional technique.BackgroundBRS may hold potential advantages in the treatment of coronary bifurcation lesions, however low radial strength and expansion capacity has been an issue with polymer‐based scaffolds. The magnesium BRS may prove suitable for bifurcation treatment as its mechanical properties are closer to those of permanent metallic drug‐eluting stents.MethodsThe study was a proof‐of‐concept study with planned inclusion of 20 patients with stable angina pectoris and a bifurcation lesion involving a large side branch (SB) > 2.5 mm with less than 50% diameter stenosis. Procedure and healing response were evaluated by optical coherence tomography (OCT). The main endpoints were a composite clinical safety endpoint and an OCT healing index at 1 month (range: 0–98).ResultsEleven patients were included in the study. The study was prematurely terminated due to scaffold fractures and embolization of scaffold fragments in three cases requiring bailout stenting with drug‐eluting stents. One patient underwent bypass surgery at 3 months due to stenosis proximal to the study segment. All SB were patent for 1 month. One‐month OCT evaluation showed strut coverage of 96.9% and no malapposition. Scaffold fractures and uncovered jailing struts resulted in a less favorable mean OCT healing index score of 10.4 ± 9.0.ConclusionsImplanting a magnesium scaffold by the provisional technique in nontrue bifurcation lesions was associated with scaffold fracture, embolization of scaffold fragments, and a high need for bailout stenting.

Comparison of Aspiration Catheters with Modified Standard Catheters for Treatment of Large Pulmonary Embolism Using an In-vitro Patho-Physiological Model

PurposeThe presented in-vitro study provides a comparison of various catheters for mechanical treatment of large-burden pulmonary embolism (PE) under standardized conditions, using a new test rig. Dedicated aspiration catheters (JETi®, Penumbra Indigo®, Aspirex®) were compared with standard catheters (Pigtail, Multi-Purpose, Balloon Catheter) applied for embolus fragmentation.Materials and MethodsEmboli prepared from porcine blood were washed into the test rig which consists of anatomical models of the pulmonary artery (PA) and of the right heart in combination with a pulsatile drive system. For all catheters, the duration of the recanalization procedure and the weight percentage (wt%) of the remaining, removed and washed-down clot fractions were evaluated. For aspiration catheters, the aspirated volume was measured.ResultsAll catheters achieved full or partial recanalization. The aspiration catheters showed a significantly (p < 0.05) lower procedure time (3:15 min ± 4:26 min) than the standard fragmentation catheters (7:19 min ± 4:40 min). The amount of thrombus removed by aspiration was significantly (p < 0.001) higher than that by fragmentation, averaging 86.1 wt% ± 15.6 wt% and 31.7 wt% ± 3.8 wt%, respectively. Nonetheless, most of the residue was fragmented into pieces of ≥ 1 mm and washed down. Only in 2 of 36 tests, a residual thrombus of 11.9 wt% ± 5.1 wt% remained in the central PA.ConclusionComparison under standardized in-vitro patho-physiological conditions showed that embolus fragmentation with standard catheters is clearly inferior to aspiration with dedicated catheters in the treatment of large-burden PE, but can still achieve considerable success.Level of EvidenceNo level of evidence, experimental study.

Isolated Enterococcus faecalis pulmonary valve endocarditis without precipitating risk factors: A case report describing delayed need for surgery three years after antimicrobial therapy.

Introduction and importanceIsolated Enterococcus faecalis pulmonary valve endocarditis (PVE) without precipitating risk factors is exceeding rare, as fewer than ten cases have been published in the literature, most of which did not require surgical intervention.Case presentationAn elderly individual presented for evaluation of dyspnea, fatigue, dizziness, weight loss, and a low-grade fever. The patient denied intravenous drug abuse, blood-borne viral infection, cardiac trauma, congenital heart disease, and immunocompromise. Echocardiography identified a large vegetation on the right pulmonary valve leaflet consistent with isolated PVE. Blood cultures grew E. faecalis. Computed tomography failed to reveal an infectious source. The patient completed a six-week course of antibiotics and was followed with serial echocardiography for three years, but subsequently developed severe pulmonic insufficiency and right heart failure necessitating pulmonary valve replacement.Clinical discussionIsolated PVE is responsible for less than 2.0% of all cases of infective endocarditis. The vast majority of reported cases are associated with risk factors and are caused by gram-positive organisms including Staphylococcus species and Streptococcus viridans. Echocardiography identifies most cases of isolated PVE. Septic embolization of vegetation fragments to lung parenchyma is common. Surgery is reserved for patients who are unresponsive to antibiotics or those who develop severe pulmonary insufficiency with symptoms of right heart failure, as seen here.ConclusionWe present an unusual case of isolated E. faecalis PVE without known risk factors that required pulmonary valve replacement three years after antimicrobial therapy.

Failure modes and effects analysis of mechanical thrombectomy for stroke discovered in human brains.

Despite advancement of thrombectomy technologies for large-vessel occlusion (LVO) stroke and increased user experience, complete recanalization rates linger around 50%, and one-third of patients who have undergone successful recanalization still experience poor neurological outcomes. To enhance the understanding of the biomechanics and failure modes, the authors conducted an experimental analysis of the interaction of emboli/artery/devices in the first human brain test platform for LVO stroke described to date. In 12 fresh human brains, 105 LVOs were recreated by embolizing engineered emboli analogs and recanalization was attempted using aspiration catheters and/or stent retrievers. The complex mechanical interaction between diverse emboli (elastic, stiff, and fragment prone), arteries (anterior and posterior circulation), and thrombectomy devices were observed, analyzed, and categorized. The authors systematically evaluated the recanalization process through failure modes and effects analysis, and they identified where and how thrombectomy devices fail and the impact of device failure. The first-pass effect (34%), successful (71%), and complete (60%) recanalization rates in this model were consistent with those in the literature. Failure mode analysis of 184 passes with thrombectomy devices revealed the following. 1) Devices loaded the emboli with tensile forces leading to elongation and intravascular fragmentation. 2) In the presence of anterograde flow, small fragments embolize to the microcirculation and large fragments result in recurrent vessel occlusion. 3) Multiple passes are required due to recurrent (15%) and residual (73%) occlusions, or both (12%). 4) Residual emboli remained in small branching and perforating arteries in cases of alleged complete recanalization (28%). 5) Vacuum caused arterial collapse at physiological pressures (27%). 6) Device withdrawal caused arterial traction (41%), and severe traction provoked avulsion of perforating and small branching arteries. Biomechanically superior thrombectomy technologies should prevent unrestrained tensional load on emboli, minimize intraluminal embolus fragmentation and release, improve device/embolus integration, recanalize small branching and perforating arteries, prevent arterial collapse, and minimize traction.

Open surgery retrieval of a missing guidewire causing cerebral infarctions after cerebral angiography: a case report

BackgroundIntra-aortic foreign body (IAFB) is uncommon, which is usually caused by a rupture of the catheter or guidewire. IAFB can cause catastrophic complications, including arrhythmia, embolization of guidewire fragments, intravascular clipping of the guidewire and vascular perforation. However, there are still no guidelines on removal and management of IAFB. Here, we present a rare case of fractured cerebral angiographic guidewires in the aorta that resulted in multiple cerebral infarctions.Case presentationA 50-year-old man experienced new cerebral infarction after cerebral angiography. Computed tomography and echocardiography demonstrated foreign bodies in his ascending aorta and aortic arch. Open surgery was successfully performed to retrieve the guidewires. The postoperation and follow-up was uneventful.ConclusionIt is very important for interventional radiologists to check the catheter and guidewire after operation and perform ultrasound or radiograph to prevent IAFB. Additionally, the effective management of IAFB requires the early detection and the selection of appropriate treatment options, as well as long-time follow up.

Management of a Fragmented Angiocatheter During Central Venous Cannulation: A Case Report and Important Lessons

Complications during central venous catheter (CVC) insertion are infrequent with an incidence of 0.1%-1%. We experienced a rare CVC complication with fragmentation of the angiocatheter at its hub during central venous cannulation while utilizing the modified Seldinger technique (ie, wire through the catheter technique). Vascular surgery was emergently required to remove the catheter fragment from the neck. Clinicians must remain vigilant during all aspects of CVC insertion, including awareness of the potential for fragmentation of the angiocatheter during its removal over the in situ guidewire. Prompt recognition and appropriate management included leaving the guidewire in place (to stabilize the distal fragmented segment) and promptly consulting vascular surgery for removal before potential vascular embolization of the angiocatheter fragment. We further recommend that all components of the insertion kit be inspected before and after patient use.

A SHORT RECURRENCE TIME OF LEFT ATRIAL MYXOMA: CASE REPORT AND LITERATURE REVIEW

Background: Recurrence of sporadic cardiac myxoma remains unusual but the seriousness of the situation justifies the realization of a surgical resection as complete as possible with post-operative clinical and echocargdiographic monitoring. Case presentation: We recall the case of myxoma of the left atriumin a 64-year-old women complicated by functional mitral stenosis and heart failure. She underwent urgent heart surgery, during which a friable tumor attached by a sessile base to the anterior atrial septum was removed. The postoperative effects were complicated by a pulmonary embolism. Eight months later, the patient consulted for exertional dyspnea with an echocardiographic image in favor of a recurrence of myxoma of the left atrium. Conclusion: Several mechanisms have been proposed to explain such recurrence, the most avoidable remain incomplete surgical resection and Implantation of embolic fragments of the original tumor in the myocardium due to a previous surgery.

Prevention of Paradoxical Cerebral Embolus with Protection System during Combination Right Atrial Clot Aspiration Thrombectomy and Closure of Patent Foramen Ovale

AbstractIn this technical case report, we describe a 41-year-old female with a history of breast cancer who was found to have a right atrial clot attached to the tip of her Port-A-Cath. During transthoracic echocardiography to evaluate her clot, she was also noted to also have a patent foramen ovale. The decision was made to perform a simultaneous right atrial endovascular aspiration thrombectomy and patent foramen ovale closure. To minimize the risk for paradoxical embolus during clot manipulation, an intravascular embolic neuroprotection device was deployed. After the procedure, it was noted on visual inspection that the device filter contained several embolic fragments. The presence of macroscopic embolic fragments in the filter baskets highlights the role of prophylactic embolic protection when performing cardiac interventions in the setting of a patent foramen ovale, particularly in the presence of a right atrial thrombus or mass.

Leptomeningeal Collateral Flow Modifies Endovascular Treatment Efficacy on Large-Vessel Occlusion Strokes.

We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1-3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08-2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09-2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04-2.90]). Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.

Missile Fragment Embolism of the Coronary Artery in a Patient with Coronary Artery Disease

A 51-year-old war veteran referred to us with typical chest pain and dyspnea on exertion. He had a history of hypertension from several years before, for which he had been prescribed anti-hypertensive medications. He also gave a history of missile fragment injury to his chest from the Iran-Iraq war, for which he had been hospitalized, but had received conservative medical treatment only. After admission and initial workup, echocardiography revealed mild left ventricular dysfunction with an ejection fraction of 45% and a metallic fragment at the diaphragmatic surface of the right ventricle. Coronary angiography showed significant stenosis at the LAD – Diagonal bifurcation, as well as a metallic fragment occluding the PDA branch of the right coronary artery. Coronary artery bypass surgery was performed successfully and the patient was discharged uneventfully. To the best of our knowledge, this is the first report of an embolized missile fragment to the coronary artery found incidentally in a patient undergoing surgery for coronary artery disease.