Clinical vignette

In-stent balloon rupture and entrapment during post-dilatation in an infarct-related artery followed by successful retrieval

Rafał Januszek1Artur Pawlik1Karol Sabatowski1Łukasz Rzeszutko12Stanisław Bartuś12
1Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
2Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland

Correspondence to:

Artur Pawlik, MD,

Department of Cardiology and Cardiovascular Interventions,

University Hospital,

Jakubowskiego 2, 30–688 Kraków, Poland,

phone: +48 12 400 22 50,

e-mail: arturo.pawlik@gmail.com

Copyright by the Author(s), 2022

DOI: 10.33963/KP.a2022.0225

Received: May 21, 2022

Accepted: July 4, 2022

Early publication date: September 23, 2022

A 49-year-old patient was admitted to the cardiology department with a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). He was treated for 3 days using aspirational thrombectomy for ischemic stroke. An echocardiogram showed preserved left ventricular ejection fraction with regional hypokinesia of the lateral and posterior wall of the left ventricle. The coronary angiography exhibited a well-organized thrombus in the mid-circumflex artery (mid-Cx) (Figure 1A).

Figure 1. A. Initial left coronary artery angiography with the thrombus in mid-Cx (the arrow). B. Post-dilatation of the stent with a 4.5 × 20 mm non-compliant balloon inflated to 24 atm. C. Control angiography showing distal marker and fragment of the defragmented balloon (the arrows); D. Retrieved distal part of the ruptured balloon and The AndraSnare Micro ASM-4 system. E. Final angiography after retrieval of the ruptured balloon. F. Intravascular ultrasound of Cx confirming good stent apposition and precluding significant calcifications
Abbreviations: Cx, circumflex artery

Aspirational thrombectomy was performed via the Export Aspiration System (Medtronic, Minneapolis, MN, US) following pre-dilatation with a 3.5 × 20 mm semi-compliant balloon. Despite inflation of the balloon, the optical coherence tomography intravascular probe did not cross the lesion. Based on angiography, a 4.0 × 38 mm drug-eluting stent was implanted. During post-dilatation, a 4.5 × 15 mm non-compliant balloon inflated at 24 atm ruptured and was removed “en-bloc” with a guidewire and guide catheter (Figure 1B). The shaft and the distal end of the ruptured balloon were entrapped in the vessel (Figure 1C). The patient remained hemodynamically stable; therefore, bailout surgery was deferred. The guiding catheter was switched to a 7F system. Attempts of crossing the lesion with Runthrough NS, BMW II and Whisper MS guidewires were unsuccessful. Eventually, the Gaia Second (Asahi Intecc Co., Nagoya, Japan) was delivered into the distal end of the vessel. A 3.0 × 20 mm semi-compliant balloon was inflated to 18 atm, allowing us to cross the defragmented balloon with 4 mm/175 cm AndraSnare Micro ASM-4 (Andramed GmbH, Reutlingen, Germany) and successfully retrieve the defragmented balloon (Figure 1E). After removal, the stent was post-dilatated with a 4.0 × 15 non-compliant balloon catheter. Intravascular ultrasound was applied to rule out significant calcifications and confirm the optimal outcome of the procedure (Figure 1F). Post-procedural hospitalization was uneventful, and the patient was discharged 3 days later.

Entrapment of an intra-coronary device is rare, but it is, nonetheless, a serious complication. Calcifications, tortuous anatomy, and non-dilatable lesions increase the risk of device entrapment [1]. In the majority of cases, balloon rupture with subsequent entrapment occurs during pre-dilatation or stent implantation. Unexpectedly, in this case, the balloon rupture and entrapment took place during post-dilatation. Moreover, the vessel was not heavily calcified or tortuous. This proves that device entrapment is unpredictable and can occur during any stage of the procedure. Devices allowing successful management of such complications should be available at every catheterization laboratory. Such devices were used in many clinical scenarios [2]. The AndraSnare Micro system is based on an angled nitinol loop allowing retrieval of foreign bodies in coronary and peripheral vessels. In the case of retrieval failure, “burying” the object under a new stent or bail-out surgical management may be considered.

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

REFERENCES

  1. Giannini F, Candilio L, Mitomo S, et al. A practical approach to the management of complications during percutaneous coronary intervention. JACC Cardiovasc Interv. 2018; 11(18): 17971810, doi: 10.1016/j.jcin.2018.05.052, indexed in Pubmed: 30236352.
  2. Kern A, Gil R, Bojko K, et al. A mysterious fluff in the ascending aorta retrieved with a snare system. Kardiol Pol. 2021; 79(4): 467468, doi: 10.33963/KP.15861, indexed in Pubmed: 33687870.

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