Recurrent Coronary Perforation During Staged PCI: A Multifactorial Sentinel Event

Recurrent coronary perforation requires reassessing anatomical, procedural, antithrombotic, and patient factors.

An 80-year-old woman with non-ST-segment elevation myocardial infarction and calcified 3-vessel disease underwent staged percutaneous coronary intervention (PCI). Circumflex stenting caused Ellis III perforation and tamponade, sealed with pericardiocentesis, autotransfusion, and 2 covered stents. One month later, another Ellis III perforation complicated conservative left anterior descending coronary artery PCI. Three covered stents failed, and the patient died. Chronic corticosteroid exposure was identified retrospectively.

Recurrence was multifactorial. Limitations included angiographic sizing without intravascular imaging and nonreversal of heparin. Corticosteroid exposure remains hypothesis-generating, not causal.

Recurrent coronary perforation should trigger systematic reassessment of vessel sizing, calcium morphology and preparation, anticoagulation management, procedural indication, and patient-level risk factors before further PCI. Long-term glucocorticoid therapy may represent an underrecognized risk factor for coronary perforation, although causality remains unproven.