Case study: successful removal of broken coronary angioplasty balloon from left main coronary artery

Clinical presentation

• 55-year-old male
• Underlying disease: hypertension
• Admit for stage PCI left main-left anterior descending artery
• 1 month ago, he presented with NSTEMI and coronary angiography showed triple vessels disease. PCI with DES was done in right coronary artery and left circumflex
• Symptom: exertional chest pain
• Echocardiography: LVEF 50%, normal wall motion

Left anterior descending artery

Left anterior descending artery

Right coronary artery :
patent stent

Right coronary artery :
patent stent

Left circumflex artery :
patent stent

Left circumflex artery :
patent stent

Procedure

Strategy: provisional side branch stenting with final kissing balloon.

• Transradial approach
• 6Fr XB 3.0 guiding catheter
• 3.0 x 38 mm DES placed from left main to left anterior descending artery

Discover the editorial webcast from the EuroPCR 2018 on Balloon catheter complications

Balloon was partially deflated and struck in left main artery. Despite several times of re-inflated and deflated balloon, it still struck.

Balloon was broken after forcefully pulled and remain in left main artery.
 

At that time wire in left anterior descending artery and shaft of balloon was pulled out.
 

Remaining balloon was occluded coronary flow resulting in acute STEMI anterior wall and hypotension.
 

Puncture both groins, one for IABP, the other for rescued guiding catheter.

Using 4mm coronary snare for retrieved balloon. Firstly, a JL catheter was used, but it was difficult to make co-axial between snare and balloon.

Finally, a 4.0 XB catheter was used to fixed snare with aortic knob with a large loop, which covered the whole aortic knop to catch the balloon successfully.

Successfully retrieved

Longitudinal stent compression from guiding catheter.

IVUS guided wiring left anterior descending artery and post dilate with non compliance balloon

Final angiographic result

Final angiogram showed good result

Final angiogram showed good result

Conclusion

• Possible cause of balloon struck in coronary artery was due to early removed balloon before it fully deflated as recommended in manual.
• Please read the manual!!!

Removal procedure

Withdrawel of the stent delivery catheter from the deployed stent:

• Deflate the balloon by pulling negative pressure on the inflation device. Larger and longer balloons will take more time (up to 30 seconds) to deflate than smaller and shorter balloons. Confirm balloon deflation under fluoroscopy and wait 10 - 15 seconds longer.
• Confirm complete balloon deflation before attempting to move the delivery system.
• If unusual resistance is felt during stent delivery system withdrawal, pay particular attention to the guiding catheter position.
• Open the hemostatic valve to allow removal of the delivery system
• Maintain position of guiding catheter and guide. Very slowly, withdraw the balloon from the stent, maintaining negative pressure, allowing movement of the myocardium to gently dislodge the balloon from the stent.