Background <p>Coronary artery pseudoaneurysms are rare vascular abnormalities that may develop after percutaneous coronary intervention, infection, or trauma. Although many cases remain asymptomatic, pseudoaneurysms may occasionally present with life-threatening complications. Delayed presentation of traumatic coronary pseudoaneurysm as acute coronary syndrome (ACS) complicated by cardiogenic shock is extremely uncommon.</p> Case presentation <p>A 74-year-old man presented with chest pain, dyspnea, hypotension, and signs of cardiogenic shock. Electrocardiography demonstrated anterior myocardial infarction. Emergency coronary angiography revealed proximal occlusion of the left anterior descending artery (LAD) associated with a giant pseudoaneurysm and severe circumflex artery stenosis. Given the patient’s hemodynamic instability and high surgical risk related to multiple comorbidities, percutaneous treatment was selected. Following restoration of coronary flow, a covered stent was implanted to seal the pseudoaneurysm. Subsequently, complex bifurcation intervention using the double kissing crush technique was performed. Residual pseudoaneurysm filling was completely eliminated with prolonged balloon inflation. Further history revealed a motor vehicle accident five months before presentation, suggesting a presumed traumatic etiology. The patient recovered uneventfully and was discharged on the fifth day.</p> Conclusions <p>This case highlights an unusual delayed presentation of traumatic giant LAD pseudoaneurysm as ACS complicated by cardiogenic shock. Careful clinical history taking may help identify traumatic etiologies. Complex percutaneous coronary intervention with covered stent implantation may represent a feasible treatment option in carefully selected high-risk patients.</p>