Presentation: He had suffered from chest pain on effort for 2 months, while he had been treated as old myocardial infarction with previous DES implantation and optimal medical therapy. Because of positive results of stress ECG, he underwent coronary angiography (CAG)
CAG showed significant focal in-stent restenosis (arrow) in the mid right coronary artery (RCA) and diffuse in-stent restenosis of full metal jacket with severe calcification (dotted lines) (Figure A).
Rotational atherectomy (burr Ø2.0mm) was successfully performed (Figure B).
A 3.5mm DCB was applicated with the support of GuideLiner (GL) following adequate dilatation with a 3.75mm high pressure balloon (Figure C).
Gentle pull-back resulted in the disruption of balloon catheter (Figure A). Despite deep intubation of both guiding catheter and Guideliner. Only the proximal part of balloon catheter without balloon itself was extracted from the patient’s body.
Twisted-guidewire technique with newly inserted Fielder FC was attempted but did not work, only making disrupted DCB moving ahead (Figure B).
A GooseNeck snare was tried to use but failed to go into the guide- extension lumen of GuideLiner due to the bulky device profile (Figure C).
Capturing disrupted DCB with GuideLiner and low profile balloon
Finally, a low profile IKAZUCHI Zero balloon (1.5 x 10mm) was carefully inserted through the GuideLiner (GL) without any resistance and inflated at the tip of GuideLiner (Figure A).
Successful entrapment of disrupted DCB using GL and balloon was achieved and all of the devices were retrieved together (Figure B).
Extracorporeal testing (Figure a’ and b’). The dotted line (pink) indicates the devices withdrawn into the guiding catheter (Figure b’)
Extracorporeal testing (Figure a’ and b’). The dotted line (pink) indicates the devices withdrawn into the guiding catheter (Figure b’)
Final result
Final excellent angiogram was achieved following 3rd DCB to the proximal lesion.
Disruption of balloon catheter is extremely rare complication and might occurred due to the lesion and device complexity in the present case (full metal jacket in the tortuous and calcified lesion, bended guiding catheter, long DCB etc.).
Previously reported technique1-3 such as twisted-wire technique and use of snare did not work for this case.
In this novel technique, adequate force to grasp long DCB was achieved by GuideLiner and inflated balloon, which theory seemed similar to the way the GL advanced smoothly with inflated anchoring balloon in “mother-in-child” technique.
According to the official device profile, GuideLiner could not accommodate both DCB catheter and IKAZUCHI Zero catheter simultaneously.
However, in advancing a IKAZUCHI Zero through the GuideLiner, there was no resistance at all even though the residual DCB catheter shaft was in it.
This mismatch could be explained by the flexibility of material and elliptical transformation of GL according to the previous reports4-5
A GuideLiner could transform elliptical and advance through the guiding catheter easily even when another guidewire had been already inserted in the guiding catheter.
A GuideLiner could transform elliptical and advance through the guiding catheter easily even when another guidewire had been already inserted in the guiding catheter.
An elliptically transformed GuideLiner could accommodate bulky and multiple devices beyond the official device profile.
An elliptically transformed GuideLiner could accommodate bulky and multiple devices beyond the official device profile.
Additionally, the use of low profile balloon with excellent cross-ability was another key-point of this technique to prevent a disrupted DCB from migrating distally in passing through the GuideLiner.
To the best of our knowledge, this is a case report of successful retrieval of disrupted longest DCB using GuideLiner and low profile balloon.
This technique allowed initial guiding catheter kept on engaging to the coronary artery without other vascular approach for retrieval, which would make additional procedure for complete revascularisation easier.
06 Jan 2020
Case study: Novel use of GuideLiner with low profile balloon for retrieval of disrupted balloon catheter
Coronary balloon fracture complications
Consult this case by Takayuki Warisawa et al. of the retrieval of disrupted balloon catheter with trapping.
Takayuki Warisawa1,2, Takanobu Mitarai2, Shunichi Doi2, Mizuho Kasahara2, Norio Suzuki2, Manabu Takai2, Hisao Matsuda2, Christopher M. Cook1, Justin E. Davies1, Yoshihiro J. Akashi2
Authors
Interventional cardiologist / Cardiologist
NTT Medical Center Tokyo - Tokyo, Japan
St.Marianna University School of Medicine - KAWASAKI-CITY, Japan
Juntendo University Graduate School of Medicine - Tokyo, Japan
Interventional cardiologist / Cardiologist
The Essex Cardiothoracic Centre - Basildon, United Kingdom
Interventional cardiologist / Cardiologist
Hammersmith Hospital - London, United Kingdom
By T. Warisawa , T. Mitarai , S. Doi , C. Cook , J. Davies
Clinical presentation
Procedure
A good start with the initial procedure!
CAG showed significant focal in-stent restenosis (arrow) in the mid right coronary artery (RCA) and diffuse in-stent restenosis of full metal jacket with severe calcification (dotted lines) (Figure A).
Rotational atherectomy (burr Ø2.0mm) was successfully performed (Figure B).
A 3.5mm DCB was applicated with the support of GuideLiner (GL) following adequate dilatation with a 3.75mm high pressure balloon (Figure C).
Discover the editorial webcast from the EuroPCR 2018 on Balloon catheter complications
2nd DCB (3.5 x 30mm) was stuck in RCA
Gentle pull-back resulted in the disruption of balloon catheter (Figure A). Despite deep intubation of both guiding catheter and Guideliner. Only the proximal part of balloon catheter without balloon itself was extracted from the patient’s body.
Twisted-guidewire technique with newly inserted Fielder FC was attempted but did not work, only making disrupted DCB moving ahead (Figure B).
A GooseNeck snare was tried to use but failed to go into the guide- extension lumen of GuideLiner due to the bulky device profile (Figure C).
Capturing disrupted DCB with GuideLiner and low profile balloon
Finally, a low profile IKAZUCHI Zero balloon (1.5 x 10mm) was carefully inserted through the GuideLiner (GL) without any resistance and inflated at the tip of GuideLiner (Figure A).
Successful entrapment of disrupted DCB using GL and balloon was achieved and all of the devices were retrieved together (Figure B).
Extracorporeal testing (Figure a’ and b’).
The dotted line (pink) indicates the devices withdrawn into the guiding catheter (Figure b’)
Extracorporeal testing (Figure a’ and b’).
The dotted line (pink) indicates the devices withdrawn into the guiding catheter (Figure b’)
Final result
Final excellent angiogram was achieved following 3rd DCB to the proximal lesion.
Discussion
A GuideLiner could transform elliptical and advance through the guiding catheter easily even when another guidewire had been already inserted in the guiding catheter.
A GuideLiner could transform elliptical and advance through the guiding catheter easily even when another guidewire had been already inserted in the guiding catheter.
An elliptically transformed GuideLiner could accommodate bulky and multiple devices beyond the official device profile.
An elliptically transformed GuideLiner could accommodate bulky and multiple devices beyond the official device profile.
Additionally, the use of low profile balloon with excellent cross-ability was another key-point of this technique to prevent a disrupted DCB from migrating distally in passing through the GuideLiner.
For comments or additional information on the Read & Share version of this case please click here
Key messages
References
Disclaimer
This case report does not reflect the opinion of PCR or PCRonline, nor does it engage their responsibility.
Additional Links
Balloon trapping technique Snare technique: Trifold Snare technique: GooseNeck Mini-STAR technique Trapping guide extension catheter technique References: coronary balloon fracture