BACKGROUND Coronary artery pseudoaneurysm is an extremely rare condition. In this report, we describe an 85-year-old hemodialysis male patient who developed a coronary artery pseudoaneurysm due to physical damage associated with coronary artery calcification. CASE REPORT An 85-year-old man on hemodialysis had undergone emergency percutaneous coronary intervention of the left anterior descending artery for acute coronary syndrome 9 years ago. He presented to the emergency room with a fever and chest pain and was admitted to the cardiology department with a urinary tract infection and acute coronary syndrome. On day 21 after admission, when the urinary tract infection had resolved, coronary angiography was performed, which revealed a pseudoaneurysm proximal to the left anterior descending artery stent. The patient was scheduled to undergo surgery due to the pseudoaneurysm's risk of rupture. Surgical manipulation was performed under cardiac arrest using the median sternotomy approach. A highly calcified coronary intima was found inside the pseudoaneurysm, which was completely ruptured on the proximal side of the pseudoaneurysm. The pseudoaneurysm was closed after endarterectomy. A coronary artery bypass graft was also performed in the great saphenous vein graft of the left anterior descending artery. Histopathological examination showed no obvious signs of infection, and a diagnosis of pseudoaneurysm was established. Postoperative contrast-enhanced computed tomography showed patency of the coronary artery bypass graft and no pseudoaneurysm recurrence. CONCLUSIONS Coronary artery pseudoaneurysms are extremely rare, but this case demonstrates that atherosclerotic changes can lead to the formation of a pseudoaneurysm in an elderly hemodialysis patient.