Abstract

Case Report

How to manage balloon entrapment during percutaneous coronary intervention of a calcified lesion “Case report”

Nassime Zaoui*, Amina Boukabous, Nadhir Bachir, Nabil Irid and Ali Terki

Published: 02 December, 2022 | Volume 7 - Issue 3 | Pages: 100-103

Percutaneous coronary angioplasty is a minimally invasive procedure aimed at unclogging a coronary artery with a low complication rate (with a serious complication rate of 3% to 7% and a mortality rate of 1.2%). Device entrapment during PCI is a rare but life-threatening complication that occurs in < 1% of PCIs and balloon entrapment comes second after coronary guidewires. We present the case of 68-years-old man, smoker, hypertensive and type2 diabetic that presents angina with evidence of ischemia on myocardial tomoscintigraphy and in whom the radial coronary angiography reveals a tight calcified mid LAD stenosis. During his PCI and after dilatation with an NC balloon 2.5 × 12 the latter refuses to deflate and remains trapped in the lesion with the appearance of pain and ST-elevation despite several attempts to dilute the product in the inflator and to burst it by overexpansion. Traction on the balloon resulted in the deep intubation of the guiding-catheter, which comes in contact with the trapped balloon, and the rupture of the latter’s hypotube, which remains inflated at the site of the lesion and mounted on the 0.014 guidewire. We put a second 0.014 guidewire distally in the LAD and twisted with the distal part of the first guidewire, then we introduced a second balloon 2.0 × 20 over the second guidewire until the distal part of the guiding-catheter and inflated to trap the stucked balloon. We gradually removed this emergency assembly that allowed us to retrieve the trapped balloon. The control injection revealed a thrombotic occlusion of the LAD treated by thrombectomy and anti-GPIIbIIIa followed by a DES 2.75 × 28 placement. The patient was discharged 48 hours later with a good LVEF. The possible balloon entrapment mechanisms are an acute recoil of a highly calcified lesion with compression of the incompletely deflated balloon, which seems to be the case in our patient, strangulation of the proximal balloon end by the guiding-catheter if the balloon is removed before complete deflation and break or bend of the hypotube. The solutions in case of undeflatable balloon entrapment are to dilute the product in the inflator, to burst it by overexpansion, to pierce it through a stiff guidewire (or through its other end on a Microcatheter or OTW balloon), to cut its outer part and let it empty passively, to introduce a second guide-wire and perform a Buddy-Balloon or to transfer the patient to Surgery. Material entrapment remains a rare but life-threatening complication, its eviction requires the choice of material size and gentle manipulations (small balloons in the event of a calcified lesion) and its management uses different techniques, the choice of which depends on the clinical and anatomical situation. 

Read Full Article HTML DOI: 10.29328/journal.jccm.1001142 Cite this Article Read Full Article PDF

Keywords:

Case report; Calcified lesion; PCI complication; Device entrapment; Undeflatable balloon; Balloon dysfunction

References

  1. Pursnani S, Korley F, Gopaul R, Kanade P, Chandra N, Shaw RE, Bangalore S. Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. Circ Cardiovasc Interv. 2012 Aug 1;5(4):476-90. doi: 10.1161/CIRCINTERVENTIONS.112.970954. Epub 2012 Aug 7. PMID: 22872053.
  2. Ferreira RM, de Souza E Silva NA, Salis LHA. Complications after elective percutaneous coronary interventions: A comparison between public and private hospitals. Indian Heart J. 2018 Jan-Feb;70(1):32-36. doi: 10.1016/j.ihj.2017.06.012. Epub 2017 Jun 27. PMID: 29455784; PMCID: PMC5902824.
  3. Aggarwal B, Ellis SG, Lincoff AM, Kapadia SR, Cacchione J, Raymond RE, Cho L, Bajzer C, Nair R, Franco I, Simpfendorfer C, Tuzcu EM, Whitlow PL, Shishehbor MH. Cause of death within 30 days of percutaneous coronary intervention in an era of mandatory outcome reporting. J Am Coll Cardiol. 2013 Jul 30;62(5):409-15. doi: 10.1016/j.jacc.2013.03.071. Epub 2013 May 9. PMID: 23665371.
  4. Movahed MR, Hashemzadeh M, Jamal MM, Ramaraj R. Decreasing in-hospital mortality of patients undergoing percutaneous coronary intervention with persistent higher mortality rates in women and minorities in the United States. J Invasive Cardiol. 2010 Feb;22(2):58-60. PMID: 20124588.
  5. Gasparini GL, Sanz-Sanchez J, Regazzoli D, Boccuzzi G, Oreglia JA, Gagnor A, Mazzarotto P, Belli G, Garbo R. Device entrapment during percutaneous coronary intervention of chronic total occlusions: incidence and management strategies. EuroIntervention. 2021 Jun 25;17(3):212-219. doi: 10.4244/EIJ-D-20-00781. PMID: 32894229.
  6. Sanz-Sánchez J, Mashayekhi K, Agostoni P, Egred M, Avran A, Kalyanasundaram A, Garbo R, Colombo A, Regazzoli D, Reimers B, Brilakis ES, Gasparini GL. Device entrapment during percutaneous coronary intervention. Catheter Cardiovasc Interv. 2022 May;99(6):1766-1777. doi: 10.1002/ccd.30160. Epub 2022 Mar 21. PMID: 35312151; PMCID: PMC9544850.
  7. Leibundgut G, Degen C, Riede F. Transcutaneous Puncture of an Undeflatable Coronary Angioplasty Balloon Catheter. Case Rep Cardiol. 2018 Sep 3;2018:6252809. doi: 10.1155/2018/6252809. PMID: 30250754; PMCID: PMC6140099.
  8. Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol. 1987 Dec 1;60(16):1260-4. doi: 10.1016/0002-9149(87)90604-7. PMID: 2961239.
  9. Leibundgut G, Degen C, Riede F. Transcutaneous Puncture of an Undeflatable Coronary Angioplasty Balloon Catheter. Case Rep Cardiol. 2018 Sep 3;2018:6252809. doi: 10.1155/2018/6252809. PMID: 30250754; PMCID: PMC6140099.
  10. Watt J, Khurana A, Ahmed JM, Purcell IF. Simple Solution for an Undeflatable Stent Balloon in the Left Main Stem. JACC Cardiovasc Interv. 2015 Dec 21;8(14):e245-6. doi: 10.1016/j.jcin.2015.07.033. Epub 2015 Nov 18. PMID: 26604055.
  11. Chang WT, Chen JY, Li YH, Tsai LM, Lee CH. A two-case series of entrapment of a ruptured balloon in the coronary artery: Avoidable complications and nonsurgical management. J Formos Med Assoc. 2015 Nov;114(11):1135-9. doi: 10.1016/j.jfma.2013.05.008. Epub 2013 Jun 18. PMID: 23791003.
  12. Desai CK, Petrasko M, Steffen K, Stys T, Stys A. Retained Coronary Balloon Requiring Emergent Open Surgical Retrieval: An Uncommon Complication Requiring Individualized Management Strategies. Methodist Debakey Cardiovasc J. 2019 Jan-Mar;15(1):81-85. doi: 10.14797/mdcj-15-1-81. PMID: 31049154; PMCID: PMC6489603.

Figures:

Figure 1

Figure 1

Figure 1

Figure 2

Figure 1

Figure 3

Figure 1

Figure 4

Figure 1

Figure 5

Figure 1

Figure 6

Figure 1

Figure 7

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?