Cerrato E, Pavani M, Barbero U, et al. - Since a life-threatening complication of PCI is Ellis grade III coronary artery perforations (G3-CAP), with lack of consensus concerning optimal management strategies, therefore, researchers analyzed all PCIs conducted in 10 European centers from 1993 to 2019, in this review. They focused on all G3CAP along with treatment strategies, in-hospital and long-term results based on Device-related (DP) and Guidewire-related (WP) perforations. The occurrence of G3-CAP was evident in 311 patients (0.29%) among 106,592 PCI (including 7,773 chronic total occlusions). The occurrence of DP was seen in 194 cases (62.4%), more frequently in proximal segments (73.2%) and often secondary to balloon dilatation (66.0%). In 38.2% of cases, procedural or in-hospital events occurred: higher mortality was noted post-DP and acute stent thrombosis 3-fold higher. Although rare and despite enhanced rates of adequate perforation sealing G3-CAP was shown to result in significant adverse events. Different patterns of G3-CAP resulted from DP and WP, and treatment strategies should be based on this classification.