SS–20 Diagnostic Pitfall in Hypotension After Complex PCI: Incidental Pericardial Effusion and Femoral Access-Site Perforation

Abstract

Introduction and Aim: Acute hypotension following percutaneous coronary intervention (PCI) requires the prompt exclusion of potentially life-threatening complications, including coronary perforation, cardiac tamponade, acute stent thrombosis, and vascular access-site complications. We present a case of hemodynamic deterioration after complex PCI in which a concomitantly detected pericardial effusion created a diagnostic challenge, while the actual cause was a perforation at the external iliac artery–common femoral artery (CFA) junction that was successfully managed by an endovascular approach.

Case Report: A 58-year-old man with hypertension and established coronary artery disease was admitted for elective PCI. He had previously undergone PCI of the left anterior descending artery (LAD) and circumflex artery (Cx) for an acute coronary syndrome in December 2025. During the index procedure, a 4.0×24 mm drug-eluting stent (DES) was implanted from the left main coronary artery extending into the LAD, a 3.5×18 mm DES was implanted in the proximal Cx, and overlapping 3.0×35 mm and 3.5×43 mm DESs were deployed from the distal right coronary artery to the ostium. Following the procedure, the patient was transferred to the coronary intensive care unit for monitoring. After removal of the right femoral arterial sheath, the patient developed tachycardia and hypotension. Bedside echocardiography demonstrated a 1-cm pericardial effusion. Given the recent complex PCI, coronary perforation with hemopericardium was initially considered the leading diagnosis, and the patient was urgently transferred back to the catheterization laboratory. However, serial blood gas analyses also demonstrated a progressive decline in hemoglobin levels, raising concern for ongoing hemorrhage. Repeat coronary angiography via the left femoral artery demonstrated patent coronary stents without evidence of coronary perforation. Subsequently, the right iliofemoral arterial system was assessed using a crossover approach from the left femoral artery. Digital subtraction angiography revealed marked active contrast extravasation consistent with arterial perforation at the external iliac artery–CFA junction. A 10×37 mm BeGraft covered stent was implanted across the perforation site. Final angiography demonstrated complete cessation of contrast extravasation with preserved distal arterial flow. Following the intervention, the patient’s blood pressure and heart rate normalized, and hemoglobin levels stabilized. Serial echocardiographic examinations showed no significant progression of the pericardial effusion, confirming that it was not responsible for the hemodynamic deterioration.

Conclusion: The detection of pericardial effusion in a patient who develops acute hypotension after complex PCI may readily direct diagnostic attention toward coronary perforation and cardiac tamponade. Nevertheless, a concomitant decline in hemoglobin should prompt immediate consideration of vascular access-site complications and retroperitoneal bleeding, particularly when femoral access has been used. After coronary complications were excluded, crossover angiography enabled rapid identification of the bleeding source, and endovascular exclusion with a covered stent achieved prompt and effective hemostasis without the need for surgical intervention.