Sequential Coronary Obstruction After Native TAVI: Immediate Acute Occlusion and Very Late Stent Compression by Aortic Wall Hematoma

Coronary obstruction is a rare but catastrophic complication of transcatheter aortic valve implantation (TAVI) associated with high mortality. While acute and delayed presentations have distinct pathophysiological mechanisms, their occurrence in the same patient is exceedingly rare. We present a unique case of a 91-year-old female who developed acute left main coronary artery (LMCA) obstruction immediately following native TAVI using a balloon-expandable valve, which was successfully treated with bail-out percutaneous coronary intervention (PCI). Three months later (> 60 days, classified as "Very Late" coronary obstruction), she presented with severe angina and heart failure. Intravascular ultrasound (IVUS) revealed extrinsic compression of the previously implanted coronary stent caused by a localized aortic wall hematoma. A repeat PCI with a stent-in-stent technique restored coronary flow, leading to complete clinical recovery. This case expands the known mechanical spectrum of very late coronary obstruction according to recent classification frameworks and highlights the vital role of intravascular imaging and multimodality assessment in diagnosis and management.