The perforation triad as a recognition-and-response pattern for balloon- or stent-related Ellis II–III coronary artery perforation during percutaneous coronary intervention

Objective Coronary artery perforation (CAP) is a rare but potentially catastrophic complication of percutaneous coronary intervention (PCI). We describe a prespecified candidate recognition pattern – the perforation triad – that may help operators identify an evolving perforation during inflation. Methods In this single-center retrospective matched case-control study, 9865 PCI procedures performed between 2020 and 2025 were screened. Forty-one balloon‐ or stent-related Ellis II–III CAP cases (0.42%) were matched 1: 1 by age, sex, American College of Cardiology/American Heart Association lesion class, and rotational atherectomy use with uncomplicated PCI controls, each contributing one stage-matched index inflation. The triad – chest or back pain during inflation, abrupt balloon-waist disappearance without balloon rupture, and ventricular extrasystole temporally linked to inflation – was prespecified before data abstraction and adjudication. Prespecified descriptive analyses covered the three components, their pairwise combinations, and component-count thresholds; no threshold optimization was undertaken. Results Among CAP cases, components were present in 78.0, 85.4, and 73.2%, respectively; the complete triad in 28 of 41 cases (68.3%; 95% confidence interval: 51.9–81.9) and in 0 of 41 selected control inflations. Control inflations meeting the pattern fell as more components were required (≥1, 20 of 41; ≥2, 10 of 41; triad, 0 of 41), with case-level sensitivity of 87.8, 80.5, and 68.3%. Tamponade requiring drainage occurred in 29.3%, and in-hospital mortality was 7.3%. Conclusion The perforation triad is a plausible recognition pattern for balloon‐ or stent-related Ellis II–III CAP. Because of retrospective sampling, selected controls, and incorporation bias, it should not be interpreted as a validated diagnostic rule or as evidence of real-world specificity; prospective inflation-level validation is required.