A Stitch in Time: Superior Epigastric Artery Injury During Emergency Pericardiocentesis

Coronary perforation during percutaneous coronary intervention (PCI) is a rare yet life-threatening complication, often necessitating emergent pericardiocentesis. However, rarely unexpected complications such as vascular injuries may arise, further complicating the clinical course. A 76-year-old lady with progressive angina underwent PCI for significant stenoses in the left anterior descending (LAD) and left circumflex (LCX) artery. The procedure was complicated by a coronary perforation in the mid-LAD, leading to cardiac tamponade. Emergent pericardiocentesis via the subxiphoid approach, guided by echocardiography, drained 300 mL of blood and temporarily stabilized the patient. A covered stent was deployed to seal the LAD perforation, but persistent bleeding suggested a secondary complication. Diagnostic evaluation, including analysis of the pericardial aspirate and repeat angiography, identified an arterial source of bleeding unrelated to the coronary perforation. Exploratory sternotomy revealed an aberrant superior epigastric artery injured during pericardiocentesis. Surgical ligation of the artery resulted in immediate hemodynamic improvement, and the patient was discharged in stable condition after a full recovery. This case highlights a rare vascular complication of pericardiocentesis, specifically an injury to the superior epigastric artery, exacerbated by anatomical variation. Such unreported injuries in the literature underscore the unpredictability of rare vascular complications even in typically safer techniques like the subxiphoid approach. A systematic, stepwise approach-combining imaging guidance, diagnostic evaluations, and prompt surgical intervention-is essential for timely management. Early recognition of vascular injury and swift multidisciplinary collaboration ensured a favorable outcome in this case, emphasizing the importance of vigilance and structured decision-making when complications arise.