Fatal coronary perforation during percutaneous coronary intervention: The medico-legal interest in establishing the correlation between in vivo imaging and post-mortem histopathology

A 64-year-old man diagnosed with chronic coronary syndrome (CCS) underwent elective percutaneous coronary intervention (PCI) to place a stent in a branch of the first diagonal artery. Fifteen minutes after the procedure, the patient suffered a cardiac arrest, which was subsequently determined to be caused by cardiac tamponade identified through ultrasound examination. Despite an hour of cardiopulmonary resuscitation, the patient died and a forensic investigation was requested by the public prosecutor. On review of the coronary angiography images, an extravasation of contrast was noted, which was classified as a type II perforation according to the Ellis classification. Autopsy revealed a hemorrhagic suffusion area on the anterior surface of the left ventricle with suspected epicardial discontinuity. Histopathological examination confirmed a complete rupture of the vessel wall in the distal section of the branch where the stent was placed, accompanied by adjacent hemorrhagic and fibrin-platelet material. The diagnosis of coronary perforation is typically made through imaging and histological confirmation is rarely obtained. In the present case, the correlation between in vivo imaging and post-mortem histopathology not only facilitated the precise localization of the coronary perforation but also had significant medico-legal implications in the assessment of presumed medical liability.