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+A 70-year-old male was admitted to our hospital for perioperative cardiac evaluation of abdominal aortic aneurysm.
+The patient had undergone coronary artery bypass grafting (CABG) for severe stenosis of the left main coronary artery (LMCA) 4 years before, which consisted of the right internal thoracic artery (RITA) to the left anterior descending artery (LAD) and saphenous vein graft (SVG) to the left circumflex artery (LCX).
+Due to continual growth of the abdominal aortic aneurysm over the years, surgery was indicated.
+Left coronary angiogram showed 90 % stenosis of the LMCA and total occlusion of both grafts.
+PCI was performed for LMCA stenosis (Fig.1).
+A 7-Fr sheath was inserted into the right femoral artery, and a CLS4 guiding catheter (Boston Scientific, Natick, MA, USA) was engaged into the left coronary artery (LCA) ostium.
+A guidewire (SION Blue, Asahi Intecc, Aichi, Japan) was inserted into the distal LAD, and another guidewire (Hi-Torque Pilot 50, Abbott Vascular, Santa Clara, California, USA) was inserted into the distal LCX.
+Intravascular ultrasound (IVUS) (Intra-focus WR, Terumo Corp, Tokyo, Japan) demonstrated heavy circumferential calcification in the LMCA lesion.
+After a 4.0 × 15-mm Quantum Maverick balloon catheter (Boston Scientific) was inflated in the lesion, LCA angiogram revealed a large dissection (Fig.2).
+A 4.0 × 28-mm Multi-Link Vision stent (Abbott Vascular) was immediately deployed.
+Angiographic image of the residual dissection disappeared and the stent was dilated by a 5.0 × 15-mm Quantum Maverick balloon catheter.
+The absence of residual dissection was confirmed by angiography after stent implantation.
+Next, LMCA-LAD and LMCA-LCX kissing balloon angioplasty was initiated using a 4.0 × 28-mm stent delivery balloon in the LAD and a 3.0 mm × 15-mm Ikazuchi balloon (Kaneka Medics, Tokyo, Japan) in the LCX.
+The final angiographic imaging showed optimal results, and IVUS imaging of the lesion showed completely sealing by the stent (Fig.3).
+A large hematoma at the femoral puncture site and local bleeding was observed after removal of the femoral sheath and manual compression was applied for haemostasis.
+The hematoma did not appear to have spread the next day and the patient was discharged from the hospital on the fifth day after PCI.
+Unexpectedly, the patient was admitted to our emergency room with new-onset chest pain and dyspnoea the next day after the discharge.
+His vital signs indicated cardiogenic shock.
+Electrocardiogram showed ST elevation in leads V1-V3.
+Although echocardiography could not detect left ventricular asynergy, a large mass on the outflow tract of right ventricular chamber was observed (Fig.4).
+Contrast-enhanced computed tomography showed a 40-mm hematoma compressing the main pulmonary artery trunk and the right ventricle (Fig.5).
+During examination, the patient suffered sudden cardiopulmonary arrest.
+He received immediate cardiopulmonary resuscitation and returned to spontaneous circulation after the insertion of a percutaneous cardiopulmonary support device.
+The patient underwent emergent surgery for the removal of the hematoma after informed consent was obtained from the patient's family.
+During surgery, large, dark red clots between the pulmonary artery trunk and aorta were observed.
+The suspected origin of the epicardial hematoma was blood oozing from the LMCA stent site.
+Despite successful surgical repair, the patient died from aortic rupture induced by external cardiac massage.