Coronary Perforation Caused by Burr Exit During Rotational Atherectomy Successfully Managed With the Ping-Pong Balloon Technique Without Covered Stent Implantation.

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention, particularly during complex procedures such as rotational atherectomy. Ellis type III perforations are associated with high morbidity and mortality and usually require covered stent implantation or embolization techniques. We report the case of an 83-year-old man undergoing rotational atherectomy of a severely calcified left anterior descending artery. An Ellis type III coronary perforation occurred following abrupt burr exit at a curved mid-LAD segment. Immediate and prolonged balloon tamponade was performed, and the ping-pong technique was used to secure distal coronary access while maintaining continuous mechanical hemostasis. Partial heparin reversal with protamine was administered under sustained balloon inflation after exclusion of cardiac tamponade, using a half-dose strategy as a temporary bridging measure. During distal rewiring, no further contrast extravasation was observed, and the guidewire crossed easily into the distal true lumen. This structured bailout strategy resulted in successful sealing of the perforation without cardiac tamponade, pericardiocentesis, or covered stent implantation. Final angiographic and clinical outcomes were favorable. A systematic follow-up angiography performed at 3 weeks demonstrated an excellent result. At 8-month follow-up, the patient remained asymptomatic with normalization of left ventricular function and sustained clinical stability. This case illustrates a rare mechanism of coronary perforation related to burr exit during rotational atherectomy and highlights a structured bailout strategy combining prolonged balloon tamponade, the ping-pong technique, and controlled partial anticoagulation reversal. This approach may allow safe stabilization and facilitate definitive management in selected cases, without challenging the established role of covered stent implantation in major coronary perforations.