Delayed Distal Coronary Perforation After Successful Covered-Stent Sealing of a Proximal Ellis Type III Rupture: A Dual-Site Mechanism.

Coronary perforation is a rare but potentially life-threatening complication of percutaneous coronary intervention. We report a case of delayed hemorrhagic pericardial effusion caused by an initially occult distal wire-related perforation after successful covered-stent sealing of a proximal Ellis type III rupture. A 67-year-old man underwent PCI for a severely calcified mid-right coronary artery lesion complicated by proximal Ellis type III perforation after high-pressure post-dilatation. The perforation was immediately sealed with a covered-stent, and early echocardiographic follow-up showed only minimal stable pericardial effusion. Seven days later, the patient re-presented with chest pain and dyspnea. Transthoracic echocardiography demonstrated a large pericardial effusion, and repeat angiography revealed distal contrast extravasation without leakage from the covered-stent segment. Balloon occlusion was initially performed in the posterior descending artery to localize the bleeding source; persistent extravasation led to reassessment and localization of the perforation to the posterolateral branch. Prolonged balloon occlusion of the posterolateral branch reduced but did not eliminate extravasation. Autologous fat embolization using a Corsair Pro microcatheter achieved complete hemostasis. This case highlights a dual-site perforation mechanism in which a clinically dominant proximal rupture may mask a concomitant distal wire-related injury, emphasizing the need for systematic distal vessel reassessment after complicated PCI.