# Managing a Right Coronary Artery Perforation, Pseudoaneurysm, and the Fight for Patency

## TL;DR

This case study describes the management of a complex coronary artery perforation and pseudoaneurysm during a heart procedure in a 76-year-old woman.

## Contribution

The paper presents a novel application of the ping-pong technique to manage perforation without reversing anticoagulation.

## Key findings

- An Ellis type III perforation was managed using balloon tamponade and pericardiocentesis.
- The ping-pong technique restored flow without reversing anticoagulation.
- A pseudoaneurysm was successfully treated with coil embolization.

## Abstract

Managing coronary perforation under anticoagulation presents a clinical dilemma. This case explores the challenge of preserving vessel patency while addressing perforation. A 76-year-old woman presented with acute chest pain and inferior ST-segment depression. Angiography revealed a small-caliber right coronary artery with faint collateral flow. During percutaneous coronary intervention, an Ellis type III perforation occurred, managed with balloon tamponade and pericardiocentesis. Using the ping-pong technique, flow was restored without reversing anticoagulation. A pseudoaneurysm developed at the perforation site, which was treated successfully with coil embolization. This case highlights the balance required between bleeding risk and ischemic burden in acute coronary syndrome. It underscores the importance of advanced percutaneous coronary intervention techniques like the ping-pong strategy for effective intervention and management of complications such as pseudoaneurysms.