When foe becomes a friend: sequential balloon tamponade, coiling, and autologous fat particle embolization for the successful seal of a refractory distal coronary perforation during a PCI

Coronary artery perforation (CAP) is a potentially severe complication of percutaneous coronary intervention (PCI) with an incidence of 0.71% and is managed conservatively in 73.3% of the cases, followed by the use of covered stents (24%), deployment of coils (0.7%), and fat embolization in 2% of cases [1]. Most large vessel perforations occur due to balloon or stent overinflation while distal vessel perforations are usually caused by the guidewire exit [2]. Furthermore, large vessel perforations are dominantly treated with covered stent implantation while distal and collateral perforations are typically amenable with coils or fat embolization with both methods having inherent advantages and disadvantages [3–5]. CAP is associated with substantial mortality and morbidity as nearly 50% of patients require pericardiocentesis for tamponade and up to 13% require emergency cardiac surgery for tamponade treatment [1]. Prompt recognition of CAP and immediate intervention during coronary angiography can significantly minimize the adverse consequences.