An unusual case of distant coronary artery perforation

Coronary perforations are likely in complex lesions like calcified coronaries or chronic total occlusions. The management is challenging in the face of hemodynamic instability. We are reporting an unusual case of coronary artery perforation. After an unsuccessful attempt to pass a guide wire in chronically occluded branch of the diagonal artery, there was type II perforation which sealed off by itself. After the procedure the patient developed cardiac tamponade for which pericardiocentesis was done. After initial improvement in hemodynamics the patient developed signs of tamponade again with continuous drainage of blood from pericardial space. A check shoot, surprisingly showed a type III perforation in the distal LAD! No hardware had been passed into the distal LAD. Retrospectively it was thought that the cause was the pericardiocentesis needle which had nicked the LAD during pericardiocentesis.