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

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.