Abstract Body (Do not enter title and authors here): Background:Percutaneous Coronary Intervention (PCI) is essential for coronary artery disease management. Coronary Artery Perforation (CAP), though rare (0.4% incidence), is a critical complication with high morbidity and mortality. As PCI techniques advance, understanding CAP outcomes becomes vital – particularly in resource-limited settings like Pakistan. This study at a major Pakistani tertiary center addresses local knowledge gaps and provides insights for managing this complication.

Research Question: What are the angiographic and clinical characteristics of patients experiencing CAP during PCI, and what are the outcomes of different management strategies in-hospital and over long-term follow-up?

Methodology: This single-center, retrospective observational study was conducted at Army Cardiac Center, Lahore. It included all CAP cases encountered during PCI over six years (January 2018 to December 2024). Patient and procedural data were collected from hospital records. Outcomes were categorized as in-hospital mortality and long-term endpoints: functional status (NYHA, CCS), repeat angiography, rehospitalization, and survival. Structured interviews and follow-up visits provided long-term data, which was analyzed using SPSS v28.

Results: Thirty patients with CAP were identified (mean age 60.2 ± 1.57 years; 70% male). Common comorbidities were hypertension (73.3%) and diabetes (53.3%). The LAD was the most frequently involved vessel (63.3%). Most perforations resulted from non-compliant balloons and hydrophilic guidewires. Covered stents were used in 76.6%(n=23) of cases; balloon tamponade in 20%(n=6). Only two cases of significant pericardial effusion leading to cardiac tamponade were encountered. In-hospital mortality was 6.7%(n=2), with overall survival at follow-up of 86.7%(n=26). Functional outcomes were favorable (NYHA I: 56.7%, CCS I: 66.7%). Repeat angiography was needed in 10% of cases(n=3). Most patients (86.7%) were managed medically post-discharge, and 76.7% avoided rehospitalization.

Conclusion: Our CAP mortality of 6.7% dramatically undercuts the 20% reported for Ellis III perforations. This outcome stems from our institutional protocol: leaving the balloon inside the stent with immediate safety testing (2 mL contrast injection) ,which enables instant inflation and tamponade during perforations. These results prove that systematic vigilance and rapid intervention optimize CAP outcomes—even in resource-limited settings