ABSTRACT: The optimal approach in managing cases complicated due to retained components in the coronary arteries during angioplasty is still not clear. In most cases, management is individualized. We report the retrieval of a partially inflated balloon with a broken shaft from the coronary system using a simple technique based on Fogarty. This did not involve the use of a snare or any other retrieval tool.
J INVASIVE CARDIOL 2011;23:E173–E176
With the expansion of interventional cardiology, the retrieval of broken fragments of angioplasty hardware (such as guidewires, angioplasty balloons, etc.) and dislodged stents has emerged as a significant problem in the catheterization laboratory despite refinements in hardware. Such a problem, when encountered in the coronary vasculature, may have grave consequences.1 Retrieval of these fragments is difficult, unpredictable, and often dangerous despite the availability of retrieval equipment like snares, forceps, baskets, etc.1,2 The occurrence of such an event in the cath lab often culminates in panic and can test the nerves of even the most experienced interventional cardiologist. Here, we report a case in which the non-deflation of a coronary balloon with subsequent breakage of its shaft occurred. This potentially fatal dual complication was resolved successfully in the nick of time with a simple percutaneous technique. There are a few reports of successful percutaneous management of broken shafts, but this is the first report in which this dual complication was successfully managed.
Case Report. A 65-year-old, diabetic male patient presented with inferior wall myocardial infarction (MI) and intractable post-MI angina. Coronary angiogram demonstrated significant double-vessel disease in the left circumflex (LCX) (Figure 1) and right coronary artery (RCA). He was taken for percutaneous transluminal coronary angioplasty with stenting to the LCX. The left coronary artery was engaged with a Judkins left guiding catheter (GC) (Medtronic Vascular, Santa Rosa, California). The lesion was crossed with a Stabilizer Plus wire (Cordis Corporation, Miami Lakes, Florida) and predilated with a 2.5 x 10 mm Firestar balloon (Cordis Corporation). Residual stenosis was treated with a 3.5 x 13 mm Pronova drug-eluting stent (Vascular Concepts, Bangalore, India). Following stent deployment, incomplete expansion was noted in the mid-portion of the stent. A new 3.5 x 10 mm Firestar balloon (Cordis Corporation) was prepared and placed in the stented segment of the artery for in-stent dilatation. On attempting to inflate the balloon, we realized that the balloon was inflating predominantly in its distal portion (Figure 2). Thus, a negative suction was applied on the balloon catheter to deflate it. However, the distal portion of the balloon did not deflate. We tried to repeat the inflation and deflation of the balloon multiple times after diluting the contrast in the inflation device, but the balloon failed to deflate. Gentle traction was given on the shaft of the balloon while maintaining the negative suction, thinking that the partially inflated balloon might come out. While traction was applied, there was no movement of the balloon within the stent. Subsequently, the shaft of the balloon came out, while the partially inflated balloon was at its original position within the stent. This confirmed that the shaft of the balloon catheter had broken. The patient developed severe chest pain with ST-segment elevation along with hypotension. Angiogram revealed an occluded LCX starting at the inlet of the stent (Figure 3). The LAD also showed TIMI-2 flow. We quickly wired the LAD to maintain the access, anticipating a later thrombogenic complication in the same. An additional 2,500 U of unfractionated heparin were also given. The cardiac surgery team was alerted and surgical retrieval of the entrapped system was planned. In the meantime, a Whisper wire (Abbott Vascular International, BVBA, Belgium) was maneuvered through the stent with difficulty and positioned in the distal artery (Figure 4). Anticipating that a sufficient length of the shaft of broken balloon had been retained inside and was extending into the GC, a 2.5 x 9 mm Maverick balloon (Boston Scientific, Natick, Massachusetts) was advanced over the second wire and positioned near the tip of the GC and inflated to 14 atm so that the proximal part of the broken balloon shaft was trapped between the outer wall of the inflated balloon and inner wall of the GC. A gentle attempt to withdraw the assembly failed to show any movement of the assembly. The balloon was quickly withdrawn. A 2 x 9 mm Maverick balloon was negotiated with great difficulty through the stent on the second wire alongside the partially inflated broken balloon (Figure 4). The balloon was quickly inflated to 5 atm and withdrawn to position it just distal to the entrapped inflated broken balloon. Gentle traction on the distal balloon showed gradual withdrawal of the whole assembly (GC with three wires and two balloons over it). Continuous traction was maintained, which resulted in retrieval of the inflated broken balloon along with its shaft out of the coronary system and circulation (Figure 5).
Check angiogram revealed restoration of flow in the LCX (Figure 6) and LAD. The procedure was then completed by recrossing the LCX and performing in-stent dilatation with a new balloon. Final angiogram showed a well-expanded stent with normal flow. The retrieved system was checked outside (Figure 7). The inflated broken balloon, when checked outside, showed an elongated and thinned-out radiolucent part of the shaft due to traction applied.
Discussion. The incidence of retained components in the coronary arteries during angioplasty has increased and is estimated to be around 0.1–0.8%.2 There are few reports of the use of different retrieval equipment, such as retrieval forceps and snares. Different techniques, such as the two-wire technique, the modified double helix technique, use of fixed wire balloon, and use of additional balloon inflation in guide, have also been described.3–9 However, poor maneuverability and rigidity of snares and forceps often prelude the use of this approach in most such cases.3
To the best of our knowledge, the present case is the first with the dual complication of a partially inflated, entrapped balloon and a broken balloon shaft. This led to faster hemodynamic instability in the patient. The possible mechanism of partial inflation and non-deflation of the balloon followed by entrapment was as follows: there was probably a kink in the balloon catheter produced by inadvertent pressure of the shaft during the procedure. This may have produced a one-way valve mechanism, leading to partial inflation by positive pressure. However, the negative suction was not enough to fully overcome the resistance of the kink. Hence, the balloon remained partially inflated. This was further complicated by breakage of the balloon shaft due to traction given while desperately trying to retrieve the entrapped balloon. By this time, the patient had developed severe chest pain along with obliteration of flow in the LCX distal to the inlet of the stent and slow flow in the LAD. This pointed to the significant obstruction being caused by the broken balloon shaft to the coronary blood flow and subsequent high chance of thrombus development.
At this point, we had four options and limited time to act. First, surgical retrieval was the best option and the cardiac surgery team was briefed of the situation. But this involved inevitable delay. Second, use of a snare in this situation may have been difficult due to its maneuverability. Third, we were aware of the double-wire technique, in which another wire is passed and both wires are intertwined.3 When pulled, the broken system is retrieved. However, in the present case, the balloon shaft was not only broken, but the balloon was inflated. Therefore, the chance of the entrapped system getting retrieved by this method was unlikely. We tried using a fourth technique described by Trehan et al, in which we inflated a second balloon in the tip of the guiding catheter with the hope that the shaft extending within the GC might become entrapped.8 A hydrophilic wire was passed with difficulty across the stent alongside the broken inflated balloon in the distal LCX. However, despite inflating a 2.5 x 9 mm balloon at high pressure, we were not successful in retrieving the balloon. Failure of this method was probably due to two reasons. First, the proximal pressure generated by the inflated balloon was not enough to overcome the resistance given by the broken inflated balloon. Second, the traction on the shaft of the entrapped balloon had resulted in its elongation and weakening. This balloon was therefore quickly taken out. As a last resort, we thought of using the Fogarty balloon technique with the help of a low-profile balloon. A new, low-profile, 2 x 9 mm Maverick balloon was advanced over the hydrophilic wire alongside the entrapped inflated balloon within the stent. With great difficulty, it was negotiated through the stent along the entrapped inflated balloon. It was then positioned just distal to the broken balloon and inflated at low pressure. A gentle traction was given on this system to see whether the whole assembly was showing any withdrawal movement. The entrapped balloon started to withdraw. Therefore, a more sustained traction was given to withdraw the whole assembly out of the coronary tree into the aorta and then out through the arterial sheath. We were aware that this maneuver carried a serious risk of injury to the proximal LCX and possibly the left main coronary artery in the form of dissection. However, at that point in time, this probably was the best percutaneous option by which the system could have been retrieved. We understand that the described technique is definitely not without risk, but is feasible in such a life-threatening situation. However, maintaining patience and perseverance complemented by guarded aggression often helps in salvaging the patient. The authors believe that knowledge of this effective Fogarty balloon technique, in addition to the established techniques for retrieval of broken angioplasty balloons, may be lifesaving in certain situations.Girish Video edited.mp4
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From the Department of Cardiology, GB Pant Hospital and Associated Maulana Azad Medical College, New Delhi, India.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 17, 2010 and accepted November 29, 2010.
Address for correspondence: Mohit D. Gupta, MD, DM, Assistant Professor of Cardiology, Room 125, Academic Block, First Floor Dept. of Cardiology, GB Pant Hospital, New Delhi-110002, India. Email: firstname.lastname@example.org