Cardiovasc Interv and Ther DOI 10.1007/s12928-013-0221-9
CASE REPORT
Retrieval of impacted broken balloon by balloon inflation in guiding catheter Vimal Mehta • Bhagya Narayan Pandit Jamal Yusuf • Saibal Mukhopadhyay • Vijay Trehan • Sanjay Tyagi
•
Received: 16 September 2013 / Accepted: 16 October 2013 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2013
Abstract Broken catheter fragment in a coronary artery during percutaneous coronary angioplasty is a rare complication. It can result in serious problems as a result of thrombus formation and embolization of broken fragment. We report an unusual complication of a broken balloon catheter during angioplasty, which was successfully retrieved by balloon inflation in guiding catheter technique. Keywords
Broken balloon Angioplasty Retrieval
Introduction Percutaneous transluminal coronary angioplasty (PTCA) is a relatively safe procedure for relieving symptoms due to ischemia resulting from coronary artery disease. Increasingly, complex lesions are being treated percutaneously because of major advancements in coronary hardware such as low profile balloons and stents. However, with increasing complexity of interventional procedures, hardware-related complications such as twisted or broken coronary balloons, guidewires, export catheter [1] and other coronary hardware are being increasingly reported [2, 3]. The above may lead to coronary dissection, thrombus formation, proximal or distal embolization, or perforation [1–3]. We describe an unusual complication in which an unruptured coronary angioplasty balloon was impacted in the
V. Mehta (&) B. N. Pandit J. Yusuf S. Mukhopadhyay V. Trehan S. Tyagi Room No. 133, Academic Block, Department of Cardiology, G. B. Pant Hospital, Maulana Azad Medical College, Jawaharlal Nehru Marg, New Delhi 110002, India e-mail: [email protected]
proximal left circumflex coronary artery (LCx) while it was being advanced for post-dilatation of the stent in distal LCx which was successfully retrieved by balloon inflation in guiding catheter.
Case report A 45-year-old, non-diabetic and non-hypertensive male patient presented with a history of increasing exertional angina NYHA III for 2 months. ECG showed ST depression and T wave inversion in lead V1–V5. Echocardiogram showed moderate hypokinesia in LAD and RCA territory with left ventricular ejection fraction of 40–45 %. Coronary angiography revealed normal left main, proximal LAD 100 % occlusion, filling retrogradely from RCA with grade III collaterals, LCx after OM1 had tubular 75–90 % stenosis, OM1 50 % stenosis and mid RCA 75–90 % stenosis. Patient was given the first option of CABG but he declined. After pretreatment with aspirin 325 mg and clopidogrel 600 mg, PTCA and stenting with a drug eluting stent to LAD was done initially. After 2 weeks, he was planned for revascularisation of both RCA and LCx (Fig. 1a). Heparin was given 100 IU/kg intravenous bolus and first PTCA to RCA was done with 3.5 9 37 mm drug eluting stent. Then, left coronary artery was engaged with JL3.5, 7F guiding catheter (Medtronic, Minneapolis, MN, USA). The LCx lesion was crossed with a Stabilizer Balance Performance Guidewire (Cordis Corporation, FL, USA) and predilated with Voyager 2.0 9 8 mm balloon (Abbott Vascular, Santa Clara, USA), drug eluting 2.75 9 21 mm stent was deployed (Fig. 1b). A Firestar 2.75 9 10 mm balloon (Cordis Corp, FL, USA), was attempted to pass into the LCx for post-stent dilatation. However, the balloon could not be negotiated into the
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V. Mehta et al. Fig. 1 a Left coronary angiogram showing tubular lesion in LCx after OM1 in RAO caudal view, b showing post-stent residual stenosis in stented segment
Fig. 2 a Thrombus formation at impacted balloon in LCx, b complete occlusion of flow in the LCx
distal LCx. It was decided to take buddy wire into LCx, but on attempting to withdraw the balloon only the shaft of balloon came out and the balloon marker did not move from its position in proximal LCx under fluoroscopy. The residual balloon shaft (which was out on table) gave an approximation of the length of trapped broken portion of balloon. It was estimated that part of the broken shaft was in guiding catheter and part of it was in left main and LCx. The broken balloon shaft was on the initial coronary guidewire. At this point, patient began to experience chest pain. Ischemic changes were observed on the electrocardiography monitor. A second guidewire Whisper (Abbott laboratories, IL, USA) was taken into the LCx. Coronary angiogram showed no forward flow in the artery beyond the balloon in the LCX artery (Fig. 2a, b). Additional 2500 IU was given to keep the ACT above 300 ms. A second balloon, Sprinter 2.5 9 6 mm (Medtronic Inc., Minneapolis, MN) was advanced over the second guidewire and positioned at the distal end of the broken balloon
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and was then inflated to 8 ATM (Fig. 3a). Inflations were given throughout the length of impacted balloon so as to dislodge the entrapped balloon and also to fragment the thrombus, so as to restore flow in the LCx. Coronary angiogram showed TIMI III flow in LCx. After this, the 2.5 9 6 mm Sprinter balloon was pulled back and inflated inside the guiding catheter to 8 ATM (Fig. 3b), so as to entrap the broken proximal shaft of the retained broken balloon in the guiding catheter. A gentle pull back on inflated balloon, guiding catheter and the guidewire en masse showed the proximal movement of the balloon marker (Fig. 3c). After this, the guiding catheter was pulled out along with the inflated balloon, coronary guidewire and the broken balloon as an assembly uneventfully (Fig. 4a, b). A final post-stent dilatation was given with a 2.75 9 9 mm Sprinter balloon using buddy wire technique after re-engaging and crossing the LCx. A check angiogram showed TIMI III flow in the LCx (Fig. 5). The retrieved broken balloon when checked outside showed
Retrieval of impacted broken balloon
Fig. 3 a Showing 2.5 9 6 mm balloon inflated (on second guidewire) at impacted balloon site, b 2.5 9 6 mm inflated balloon on the second guidewire (arrow) in guiding catheter catching the shaft of
broken balloon in the guiding catheter, c the guiding catheter being pulled out along with the inflated balloon, coronary guidewire and the broken balloon as an assembly
Fig. 4 a Broken distal shaft of 2.75 9 10 mm balloon with part of it in guiding catheter on the coronary guidewire as taken out from the LCx, b retrieved distal broken shaft of balloon (arrow) and proximal shaft of balloon (arrowhead) as examined on table
that the balloon had broken at the junction of the metallic part of shaft and the radiolucent part of the shaft (at the start of the monorail). Patient had an uncomplicated course in the post-intervention ICU and was discharged 2 days after the procedure on dual antiplatelet therapy.
Discussion Transcatheter retrieval of retained catheter fragments is an appealing management strategy but requires expertise [3]. Surgical removal is necessary when either transcatheter attempts fail or are not possible [4, 5]. The interventional cardiologist should be familiar with the percutaneous techniques of foreign body removal such as intertwined guidewires, balloon inflation technique, baskets and snares [3]. In the present case, the impacted balloon was retrieved quickly without extensive manipulation inside the coronary lumen, thus avoiding the risk of dissection and thrombosis.
A combination of factors probably led to dehiscence of the balloon shaft which included, (a) acute bend in proximal LCx, (b) excessive force used to push the balloon across the acute bend, (c) inadvertent rotational torque being applied to the balloon while it was being pushed, (d) the balloon not being coaxial to the proximal LCx lumen which was further precipitated by proximal stent struts, and (e) coronary spasm which further entrapped the balloon. Hence, although forceful push did result in some advancement of balloon in LCx, this also resulted in the balloon being entrapped (impacted) such that gentle pull back did not result in any movement. At this point, forceful pullback resulted in complete tearing of the balloon shaft at its weakest point, i.e., at the steel–plastic junction where the monorail starts. Excessive manipulation of the balloon catheter and relatively forceful advancement may have caused breakage of shaft in our case. Hence, extra care with manipulation should be taken when advancing the balloon to tortuous
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formation at the site of broken balloon that got relieved after balloon inflation which was taken over second guidewire. There was no hemodynamic compromise or any arrhythmias during the procedure. To prevent thrombus formation with possible occlusion of the left main coronary artery additional heparin was given to increase the ACT to 300 ms. Although balloon inflation assisted retrieval has been used since long [2, 3] and this technique has been used for removal of various foreign bodies in coronary tree, use of balloon inflation in guiding catheter for removal of broken balloon has been described only once before in literature [11]. The described technique is especially unique since it facilitates rapid and complete removal of the entrapped fragment with routine PCI hardware, reducing the time and complexity of the procedure. More so, there was minimal manipulation required which obviated potential dissection or large thrombus formation inside the coronary lumen. Fig. 5 Coronary angiogram in RAO caudal view showing TIMI III flow in LCx
vessels and over bends. Inherent manufacturing defect in the balloon catheter can also result in breakage of balloon. Coronary spasm can also result in entrapment of balloon catheter [6], although intracoronary nitroglycerine was given in our patient when we encountered difficulty in balloon manipulation. Balloon catheter consists of a steel hypodermic tube shaft bonded to a distal plastic segment. Separation likely occurred at the steel–plastic junction as a result of inadvertent rotation and manipulation of the balloon catheter. Techniques used to retrieve partly retained hardware from the coronary vasculature include intracoronary vasodilators to relieve spasm [6] or passage of a second wire and balloon to dilate the area of entrapment [7], intertwining techniques [8] and use of snare, retrieval forceps or basket [3, 9]. Snares are useful mostly in proximal arteries or when a part of the equipment protrudes from the coronaries into the ascending aorta [10]. However, snares are rigid and their maneuverability is also poor which precludes this approach for more distal and tortuous vessels. With our technique, the balloon fragments never freely protruded into the ascending aorta so there was no risk of embolization to systemic artery as the broken balloon shaft was on coronary guidewire. In a case where the broken catheter fragment is on the coronary guidewire, all attempts should be made not to let the broken fragment slip off the guidewire. In case that happens, the retrieval of broken fragment may become difficult or impossible. Thrombus formation may occur over the retained broken shaft of balloon, which may result in thrombotic occlusion of the coronary artery or systemic embolization when a broken fragment protrudes in ascending aorta. Patient did have severe chest pain during the procedure due to thrombus
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Acknowledgement The authors gratefully acknowledge the technical support by Mr. Sushil Kumar. Conflict of interest
We have no conflict of interest.
References 1. Mehta V, Pandit BN, Trehan V. Retrieval of broken export catheter during primary angioplasty. Int J Angiol. 2013;22:185–8. 2. Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol. 1987;60:1260–4. 3. Paulus BM, Fischell TA. Retrieval devices and techniques for the extraction of intravascular foreign bodies in the coronary arteries. J Interv Cardiol. 2010;23:271–6. 4. Rosario PG, Donahoo JS. Coronary artery endarterectomy for retrieval of entrapped percutaneous angioplasty catheter. Ann Thorac Surg. 1996;61:218–9. 5. Rizzo TF, Werres R, Ciccone J, karanam R, Shah S. Entrapment of an angioplasty balloon catheter: a case report. Cathet Cardiovasc Diagn. 1988;14:255–7. 6. Breisblatt WM. Inflated balloon entrapped in a calcified coronary stenosis. Cathet Cardiovasc Diagn. 1993;29:224–8. 7. Colombo A, Skinner JM. Balloon entrapment in a coronary artery: potential serious complications of balloon rupture. Cathet Cardiovasc Diagn. 1990;19:23–5. 8. Gurley JC, Booth DC, Hixson C, Smith MD. Removal of retained intracoronary percutaneous transluminal coronary angioplasty equipment by a percutaneous twin guidewire method. Cathet Cardiovasc Diagn. 1990;19:251–6. 9. Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol. 2007;19:E230–4. 10. Mikolich JR, Hanson MW. Transcatheter retrieval of intracoronary detached angioplasty guidewire segment. Cathet Cardiovasc Diagn. 1988;15:44–6. 11. Trehan V, Mukhopadhyay S, Yusuf J, Ramgasetty UC, Mukherjee S, Arora R. Intracoronary fracture and embolization of a coronary angioplasty balloon catheter: retrieval by a simple technique. Catheter Cardiovasc Interv. 2003;59:473–7.
CASE REPORT
Retrieval of impacted broken balloon by balloon inflation in guiding catheter Vimal Mehta • Bhagya Narayan Pandit Jamal Yusuf • Saibal Mukhopadhyay • Vijay Trehan • Sanjay Tyagi
•
Received: 16 September 2013 / Accepted: 16 October 2013 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2013
Abstract Broken catheter fragment in a coronary artery during percutaneous coronary angioplasty is a rare complication. It can result in serious problems as a result of thrombus formation and embolization of broken fragment. We report an unusual complication of a broken balloon catheter during angioplasty, which was successfully retrieved by balloon inflation in guiding catheter technique. Keywords
Broken balloon Angioplasty Retrieval
Introduction Percutaneous transluminal coronary angioplasty (PTCA) is a relatively safe procedure for relieving symptoms due to ischemia resulting from coronary artery disease. Increasingly, complex lesions are being treated percutaneously because of major advancements in coronary hardware such as low profile balloons and stents. However, with increasing complexity of interventional procedures, hardware-related complications such as twisted or broken coronary balloons, guidewires, export catheter [1] and other coronary hardware are being increasingly reported [2, 3]. The above may lead to coronary dissection, thrombus formation, proximal or distal embolization, or perforation [1–3]. We describe an unusual complication in which an unruptured coronary angioplasty balloon was impacted in the
V. Mehta (&) B. N. Pandit J. Yusuf S. Mukhopadhyay V. Trehan S. Tyagi Room No. 133, Academic Block, Department of Cardiology, G. B. Pant Hospital, Maulana Azad Medical College, Jawaharlal Nehru Marg, New Delhi 110002, India e-mail: [email protected]
proximal left circumflex coronary artery (LCx) while it was being advanced for post-dilatation of the stent in distal LCx which was successfully retrieved by balloon inflation in guiding catheter.
Case report A 45-year-old, non-diabetic and non-hypertensive male patient presented with a history of increasing exertional angina NYHA III for 2 months. ECG showed ST depression and T wave inversion in lead V1–V5. Echocardiogram showed moderate hypokinesia in LAD and RCA territory with left ventricular ejection fraction of 40–45 %. Coronary angiography revealed normal left main, proximal LAD 100 % occlusion, filling retrogradely from RCA with grade III collaterals, LCx after OM1 had tubular 75–90 % stenosis, OM1 50 % stenosis and mid RCA 75–90 % stenosis. Patient was given the first option of CABG but he declined. After pretreatment with aspirin 325 mg and clopidogrel 600 mg, PTCA and stenting with a drug eluting stent to LAD was done initially. After 2 weeks, he was planned for revascularisation of both RCA and LCx (Fig. 1a). Heparin was given 100 IU/kg intravenous bolus and first PTCA to RCA was done with 3.5 9 37 mm drug eluting stent. Then, left coronary artery was engaged with JL3.5, 7F guiding catheter (Medtronic, Minneapolis, MN, USA). The LCx lesion was crossed with a Stabilizer Balance Performance Guidewire (Cordis Corporation, FL, USA) and predilated with Voyager 2.0 9 8 mm balloon (Abbott Vascular, Santa Clara, USA), drug eluting 2.75 9 21 mm stent was deployed (Fig. 1b). A Firestar 2.75 9 10 mm balloon (Cordis Corp, FL, USA), was attempted to pass into the LCx for post-stent dilatation. However, the balloon could not be negotiated into the
123
V. Mehta et al. Fig. 1 a Left coronary angiogram showing tubular lesion in LCx after OM1 in RAO caudal view, b showing post-stent residual stenosis in stented segment
Fig. 2 a Thrombus formation at impacted balloon in LCx, b complete occlusion of flow in the LCx
distal LCx. It was decided to take buddy wire into LCx, but on attempting to withdraw the balloon only the shaft of balloon came out and the balloon marker did not move from its position in proximal LCx under fluoroscopy. The residual balloon shaft (which was out on table) gave an approximation of the length of trapped broken portion of balloon. It was estimated that part of the broken shaft was in guiding catheter and part of it was in left main and LCx. The broken balloon shaft was on the initial coronary guidewire. At this point, patient began to experience chest pain. Ischemic changes were observed on the electrocardiography monitor. A second guidewire Whisper (Abbott laboratories, IL, USA) was taken into the LCx. Coronary angiogram showed no forward flow in the artery beyond the balloon in the LCX artery (Fig. 2a, b). Additional 2500 IU was given to keep the ACT above 300 ms. A second balloon, Sprinter 2.5 9 6 mm (Medtronic Inc., Minneapolis, MN) was advanced over the second guidewire and positioned at the distal end of the broken balloon
123
and was then inflated to 8 ATM (Fig. 3a). Inflations were given throughout the length of impacted balloon so as to dislodge the entrapped balloon and also to fragment the thrombus, so as to restore flow in the LCx. Coronary angiogram showed TIMI III flow in LCx. After this, the 2.5 9 6 mm Sprinter balloon was pulled back and inflated inside the guiding catheter to 8 ATM (Fig. 3b), so as to entrap the broken proximal shaft of the retained broken balloon in the guiding catheter. A gentle pull back on inflated balloon, guiding catheter and the guidewire en masse showed the proximal movement of the balloon marker (Fig. 3c). After this, the guiding catheter was pulled out along with the inflated balloon, coronary guidewire and the broken balloon as an assembly uneventfully (Fig. 4a, b). A final post-stent dilatation was given with a 2.75 9 9 mm Sprinter balloon using buddy wire technique after re-engaging and crossing the LCx. A check angiogram showed TIMI III flow in the LCx (Fig. 5). The retrieved broken balloon when checked outside showed
Retrieval of impacted broken balloon
Fig. 3 a Showing 2.5 9 6 mm balloon inflated (on second guidewire) at impacted balloon site, b 2.5 9 6 mm inflated balloon on the second guidewire (arrow) in guiding catheter catching the shaft of
broken balloon in the guiding catheter, c the guiding catheter being pulled out along with the inflated balloon, coronary guidewire and the broken balloon as an assembly
Fig. 4 a Broken distal shaft of 2.75 9 10 mm balloon with part of it in guiding catheter on the coronary guidewire as taken out from the LCx, b retrieved distal broken shaft of balloon (arrow) and proximal shaft of balloon (arrowhead) as examined on table
that the balloon had broken at the junction of the metallic part of shaft and the radiolucent part of the shaft (at the start of the monorail). Patient had an uncomplicated course in the post-intervention ICU and was discharged 2 days after the procedure on dual antiplatelet therapy.
Discussion Transcatheter retrieval of retained catheter fragments is an appealing management strategy but requires expertise [3]. Surgical removal is necessary when either transcatheter attempts fail or are not possible [4, 5]. The interventional cardiologist should be familiar with the percutaneous techniques of foreign body removal such as intertwined guidewires, balloon inflation technique, baskets and snares [3]. In the present case, the impacted balloon was retrieved quickly without extensive manipulation inside the coronary lumen, thus avoiding the risk of dissection and thrombosis.
A combination of factors probably led to dehiscence of the balloon shaft which included, (a) acute bend in proximal LCx, (b) excessive force used to push the balloon across the acute bend, (c) inadvertent rotational torque being applied to the balloon while it was being pushed, (d) the balloon not being coaxial to the proximal LCx lumen which was further precipitated by proximal stent struts, and (e) coronary spasm which further entrapped the balloon. Hence, although forceful push did result in some advancement of balloon in LCx, this also resulted in the balloon being entrapped (impacted) such that gentle pull back did not result in any movement. At this point, forceful pullback resulted in complete tearing of the balloon shaft at its weakest point, i.e., at the steel–plastic junction where the monorail starts. Excessive manipulation of the balloon catheter and relatively forceful advancement may have caused breakage of shaft in our case. Hence, extra care with manipulation should be taken when advancing the balloon to tortuous
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V. Mehta et al.
formation at the site of broken balloon that got relieved after balloon inflation which was taken over second guidewire. There was no hemodynamic compromise or any arrhythmias during the procedure. To prevent thrombus formation with possible occlusion of the left main coronary artery additional heparin was given to increase the ACT to 300 ms. Although balloon inflation assisted retrieval has been used since long [2, 3] and this technique has been used for removal of various foreign bodies in coronary tree, use of balloon inflation in guiding catheter for removal of broken balloon has been described only once before in literature [11]. The described technique is especially unique since it facilitates rapid and complete removal of the entrapped fragment with routine PCI hardware, reducing the time and complexity of the procedure. More so, there was minimal manipulation required which obviated potential dissection or large thrombus formation inside the coronary lumen. Fig. 5 Coronary angiogram in RAO caudal view showing TIMI III flow in LCx
vessels and over bends. Inherent manufacturing defect in the balloon catheter can also result in breakage of balloon. Coronary spasm can also result in entrapment of balloon catheter [6], although intracoronary nitroglycerine was given in our patient when we encountered difficulty in balloon manipulation. Balloon catheter consists of a steel hypodermic tube shaft bonded to a distal plastic segment. Separation likely occurred at the steel–plastic junction as a result of inadvertent rotation and manipulation of the balloon catheter. Techniques used to retrieve partly retained hardware from the coronary vasculature include intracoronary vasodilators to relieve spasm [6] or passage of a second wire and balloon to dilate the area of entrapment [7], intertwining techniques [8] and use of snare, retrieval forceps or basket [3, 9]. Snares are useful mostly in proximal arteries or when a part of the equipment protrudes from the coronaries into the ascending aorta [10]. However, snares are rigid and their maneuverability is also poor which precludes this approach for more distal and tortuous vessels. With our technique, the balloon fragments never freely protruded into the ascending aorta so there was no risk of embolization to systemic artery as the broken balloon shaft was on coronary guidewire. In a case where the broken catheter fragment is on the coronary guidewire, all attempts should be made not to let the broken fragment slip off the guidewire. In case that happens, the retrieval of broken fragment may become difficult or impossible. Thrombus formation may occur over the retained broken shaft of balloon, which may result in thrombotic occlusion of the coronary artery or systemic embolization when a broken fragment protrudes in ascending aorta. Patient did have severe chest pain during the procedure due to thrombus
123
Acknowledgement The authors gratefully acknowledge the technical support by Mr. Sushil Kumar. Conflict of interest
We have no conflict of interest.
References 1. Mehta V, Pandit BN, Trehan V. Retrieval of broken export catheter during primary angioplasty. Int J Angiol. 2013;22:185–8. 2. Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol. 1987;60:1260–4. 3. Paulus BM, Fischell TA. Retrieval devices and techniques for the extraction of intravascular foreign bodies in the coronary arteries. J Interv Cardiol. 2010;23:271–6. 4. Rosario PG, Donahoo JS. Coronary artery endarterectomy for retrieval of entrapped percutaneous angioplasty catheter. Ann Thorac Surg. 1996;61:218–9. 5. Rizzo TF, Werres R, Ciccone J, karanam R, Shah S. Entrapment of an angioplasty balloon catheter: a case report. Cathet Cardiovasc Diagn. 1988;14:255–7. 6. Breisblatt WM. Inflated balloon entrapped in a calcified coronary stenosis. Cathet Cardiovasc Diagn. 1993;29:224–8. 7. Colombo A, Skinner JM. Balloon entrapment in a coronary artery: potential serious complications of balloon rupture. Cathet Cardiovasc Diagn. 1990;19:23–5. 8. Gurley JC, Booth DC, Hixson C, Smith MD. Removal of retained intracoronary percutaneous transluminal coronary angioplasty equipment by a percutaneous twin guidewire method. Cathet Cardiovasc Diagn. 1990;19:251–6. 9. Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol. 2007;19:E230–4. 10. Mikolich JR, Hanson MW. Transcatheter retrieval of intracoronary detached angioplasty guidewire segment. Cathet Cardiovasc Diagn. 1988;15:44–6. 11. Trehan V, Mukhopadhyay S, Yusuf J, Ramgasetty UC, Mukherjee S, Arora R. Intracoronary fracture and embolization of a coronary angioplasty balloon catheter: retrieval by a simple technique. Catheter Cardiovasc Interv. 2003;59:473–7.
