Acute stent thrombosis due to stent underexpansion managed with rotational atherectomy

•We illustrate a dramatic consequence of stent underexpansion.•This is the first report of acute thrombosis in a stent due to underexpansion in the setting of STEMI.•It was managed by rotational atherectomy within the stent.•Despite the concerns of rotablation within a stent, it is feasible with good clinical results.

Stent underexpansion is a well known risk factor for stent thrombosis. We report a case of acute stent thrombosis which occurred after primary percutaneous coronary intervention to the right coronary artery for an inferior ST-elevation myocardial infarction. Minutes after completion of the procedure, the patient had acute stent thrombosis, manifested by new chest pain and new ST-elevation. IVUS showed the stent to be underexpanded. Despite high pressure balloon inflation, the stent remained underexpanded. This was then managed with rotational atherectomy within the underexpanded stent, followed by high-pressure balloon dilatation and deployment of another stent within it.