Rami N. Khouzam , MD , Rajvir Dahiya , MD and Richard Schwartz , MD

A 56-year-old male with coronary artery disease presented with angina, nonspecific electrocardiographic changes, and elevated troponins. Coronary angiography revealed total occlusion of a stent in the circumflex artery, where another was deployed—his 67th stent. The patient had 28 catheterizations over 10 years, with stents placed in his native coronary arteries as well as in 3 bypass grafts. All stents were placed to relieve his angina, refractory to maximal medical treatment and transmyocardial laser revascularization. Stents can be a great tool to help revascularization and relieve symptoms; unfortunately, they are prone to thrombosis and restenosis. If they fail while medical management is maximized unsuccessfully, alternative tools are lacking. This case raises many questions: “How much is too much?” “Are there guidelines?” and “What else can be offered for symptom relief?” More studies are needed to evaluate impact on quality of life versus risks in this multistent population. LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; OM = obtuse marginal branch of the circumflex coronary artery; RCA = right coronary artery.