Tehran University of Medical Sciences The Research in Heart Yield and Translational Medicine (RHYTHM) 3115-7270 21 3 2026 05 24 243 248 EN Mohsen Sadeghi Ghahroodi Atherosclerosis Research Center, Clinical Sciences Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran Maryam Moshkani Farahani Atherosclerosis Research Center, Clinical Sciences Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran Seyed Javad Davari-Sani Atherosclerosis Research Center, Clinical Sciences Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran 2025 08 03 2026 05 10 Background: Delayed coronary artery compression because of a retained epicardial shotgun pellet is an exceptionally rare complication of penetrating cardiac trauma. Its optimal diagnosis and management are not well established. Case Presentation: We describe a 40-year-old man who presented with new-onset exertional chest pain 4 months after sustaining a shotgun pellet injury to the chest. The initial injury was managed with an emergency thoracotomy for hemopericardium and pulmonary repair, during which several epicardial pellets were left in situ. At our center, examination revealed inferior wall hypokinesia on ultrasonography. Coronary angiography demonstrated high-grade stenosis of the mid-right coronary artery caused by external compression from an adjacent retained pellet. Intravascular ultrasound (IVUS) confirmed extrinsic compression with an intact vessel wall. The patient was successfully treated with percutaneous implantation of a new-generation covered stent, resulting in immediate symptom relief and restoration of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. Conclusion: This case highlights a rare mechanism of delayed posttraumatic myocardial ischemia and demonstrates that percutaneous endovascular stenting with a covered stent is a safe and effective minimally invasive alternative to high-risk redo surgery in selected patients. The use of IVUS was crucial in confirming the diagnosis and guiding the therapeutic strategy. https://jthc.tums.ac.ir/index.php/jthc/article/view/2324 https://jthc.tums.ac.ir/index.php/jthc/article/download/2324/1278