A 62-year-old male patient who suffered from progressive angina pectoris for the last 3 months was accepted for coronary angiography, and critical distal stenosis of the left circumflex artery (Cx) was detected (Fig. 1a). A 2.5×15 mm Xcience coronary stent (Abbott Med, Illinois, USA) was implanted, and the final angiographic imaging showed a small intramyocardial vessel perforation at the distal end of the obtuse marginal artery due to use of a 0.014-inch hydrophilic guidewire (Fielder, Asahi Med, Tokyo, Japan) (Fig. 1b; Video 1). No pericardial effusion was detected, and the patient was transferred to the coronary care unit for close follow-up of hemodynamic compromise and/or new pericardial effusion development. One hour after the angioplasty procedure, a small cystic cavity was observed inside the inferior wall of the left ventricle due to intramyocardial hematoma and a pigtail catheter was placed into the pericardial sac percutaneously from the subxiphoid approach (Fig. 1c, 1d; Video 2). Hemodynamic status of the patient ameliorated rapidly by pericardiocentesis, but 5 minutes later, a big thrombus (Fig. 1e; Video 3) was observed at the left main bifurcation, which was treated by T and Protrusion (TAP) stenting technique and final kissing dilatation by Nexgen bare metal stents (4.5×19 mm and 4.0×16 mm) (Meril Med, Mumbai, India) after intravenous administration of 70/kg unfractionated heparin (UFH) (Fig. 1f; Video 4). Calculated activated clotting time (ACT) was 280 seconds. At the 75th minute after the procedure, moderate pericardial effusion and long cystic cavity was observed inside the inferolateral wall of the left ventricle (Fig. 1g and 1h; Video 5). During the first shot of angiography, a bigger extravasation was observed in the distal Cx, and intravenous protamine 5000 IU was administered immediately. A 2.0×15 mm MiniTrek (Abbott Med, Illinois, USA) coronary balloon catheter was inflated at the distal part of the obtuse marginal artery. The blood was aspirated and re-administered to the circulation from the femoral vein introducer sheath. A Finecross microcatheter (Asahi Med, Tokyo, Japan) was advanced to the distal part of the obtuse marginal branch, but unfortunately, a pushable coil could not be advanced due to the steep angle of the Cx ostium originating from the left main coronary artery (LMCA). However, because of acute re-thrombosis of LMCA (Video 6) and reaccumulation of pericardial effusion, the patient had to undergo an emergent cardiac surgery. A saphenous vein graft was ligated to left anterior descending artery (LAD), and a big myocardial dissection and rupture area were observed at the inferolateral part of the left ventricle (Fig. 1i; Video 7). Despite successful repair being done and an intraaortic balloon pump being introduced, the patient could not be leaned from a heart–lung pump. The patient died due to cardiogenic shock and left ventricular failure.
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