Recurrent Cardiac Tamponade Following Rotablator-Associated Coronary Perforation Treated with Additional Covered Stent Implantation.

Rotablator-associated coronary perforation can be fatal if bailout is delayed. Successful bailout is typically defined as the disappearance of contrast extravasation after a haemostatic intervention. We report a case of recurrent cardiac tamponade in the subacute phase, wherein haemostasis appeared to have been achieved on angiography following the implantation of a covered stent during the index procedure.A 61-year-old male underwent a percutaneous coronary intervention with a rotator placed in the middle of the left ascending artery. Coronary perforation occurred during rotablation and was treated with a covered stent. However, cardiac tamponade recurred on postoperative day 30. Emergency coronary angiography was performed, and no contrast extravasation was observed on angiography. However, intravascular ultrasonography was performed to clarify the cause of the recurrent pericardial effusion and revealed that the distal edge of the covered stent was not fully attached to the vessel wall due to protruding calcification. Another covered stent was placed distal to the previous stent for sealing the malapposed site. There was no recurrence of pericardial effusion.Malapposition of covered stents may not be detected by angiography alone, potentially resulting in recurrent bleeding. Intravascular imaging is an effective tool to confirm adequate stent apposition.