Pericardial tamponade in percutaneous coronary interventions

Introduction: The incidence of coronary artery perforation during percutaneous coronary interventions (PCI) is approximately 0.37%. The most common causes include interventions on chronic total occlusions (CTO), lesions with pronounced and excessive calcification, as well as the increasingly frequent use of atherectomy, rotational atherectomy (rotablation), and high-pressure balloons. Rare cases of spontaneous perforations have also been described. The aim of this paper is to present a patient with coronary artery perforation during a standard PCI procedure, with particular emphasis on the diagnostic and therapeutic challenges in the event of cardiac tamponade. Case Presentation: Patient M.S., aged 65, was hospitalized for elective coronary angiography. Angiography revealed no significant lesions in the left main coronary artery, LAD, or circumflex artery. The distal segment of the RCA was diffusely atherosclerotic and suboccluded. PCI of the distal RCA segment was performed. After advancing the Whisper LS coronary guidewire, contrast retention was observed in the projection of a small side branch, initially interpreted as an intramural hematoma. The patient remained hemodynamically stable, and the procedure was continued with stent implantation. After completion of the procedure, the contrast shadow increased. One hour later, the patient's condition deteriorated, presenting with chest pain, tachycardia (~100/min), hypotension (80/60 mmHg), and an episode of syncope. Echocardiography confirmed pericardial effusion with signs of impending tamponade. Emergency pericardiocentesis was performed, evacuating 850 mL of blood. Conclusion: PCI procedures are becoming increasingly complex, which raises the risk of rare but serious complications such as coronary artery perforation. A particular challenge is their timely recognition, especially in distal lesions. Despite technological advances, mortality remains significant, underscoring the importance of rapid diagnosis and an appropriate therapeutic approach.