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Air embolism caused by balloon rupture resolved by manual thrombectomy catheter aspiration
Cardiovascular Revascularization Medicine 12 (2011) 129 – 130
Air embolism caused by balloon rupture resolved by manual thrombectomy catheter aspiration Gianluca Rigatelli, Fabio Dell'Avvocata, Massimo Giordan, Paolo Cardaioli Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy Received 7 June 2010; revised 18 June 2010; accepted 24 June 2010
A 68-year-old lady with acute anterolateral myocardial infarction was referred to our center 3 h from symptom onset for emergent coronarography and percutaneous coronary intervention. Administration of abciximab was started immediately upon admission to the catheterization
laboratory. The coronary angiography revealed a paraostial occlusion of the left anterior descending (LAD) coronary artery (Fig. 1, Panel A) and normal left circumflex (LCx) and right coronary artery. Recanalization of the LAD was obtained after multiple dilation with a
Fig. 1. (Panel A) Emergent coronary angiography revealed a para-ostial occlusion of the left anterior descending coronary artery (LAD) and normal left circumflex coronary artery (LCx). (Panel B) Recanalization of LAD: a residual stenosis of the proximal LAD and its first diagonal branch was apparent. (Panel C) After stenting of the LAD, simultaneous kissing balloon inflation was performed: note (arrow) the rupture of the small 1.5×15-mm balloon with a mixed air/ contrast medium back flow presumably in the LCx and in the LAD (Panel D). (Panel E) Manual aspiration with a 6F Export catheter in both LCx and LAD with complete restoration of TIMI 3 blood flow in both vessels (Panel F). 1553-8389/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2010.06.007
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G. Rigatelli et al. / Cardiovascular Revascularization Medicine 12 (2011) 129–130
2.0×20-mm and a 2.0×30-mm angioplasty balloon (Panel B): the residual stenosis and ostial LAD and first diagonal branch were treated with a Vision 2.5×18-mm bare metal stent (Abbot Vascular, Abbott Park, IL, USA) and kissing balloon inflation was performed after wiring the diagonal branch. A Sprinter NC 2.75×12-mm balloon catheter for the LAD and a Sprinter Legend 1.5×15-mm balloon catheter (Medtronic, Minneapolis, MN, USA) for the diagonal branch were simultaneously inflated at 14 atm, but suddenly after the start of the inflation, the 1.5-mm balloon ruptured with back air embolism in the LCx and in the LAD (Panel C) resulting in complete left coronary artery no-reflow, cardiac arrest, and ventricular fibrillation (Panel D). The patient was immediately treated with cardiac massage, intravenous adrenalin, and ventilation which were all unsuccessful. Because of mechanical dissociation and no-reflow, while the IABP was set to emergent use, the LCx was wired and manual aspiration with a 6F Export thrombectomy catheter (Medtronic) was performed in both the LAD and LCx (Panel E) with complete and immediate TIMI 3 blood flow restoration and increase of blood pressure to 115/80 mmHg (Panel F). The patient was transferred in the ICU and was discharged after 7 days without other complications. Manual thrombectomy catheters were conceived for treating distal embolization and for retrieving the thrombus
during acute myocardial infarction. Recent studies have suggested a certain benefit from their use in acute myocardial infarction but with a variance in outcomes probably depending on specific structural differences of different devices [1,2]. Although the small amount of air in a 1.5-mm balloon was unlikely to cause massive air embolism, it could exacerbate a thrombotic hypercoagulable state in a patient already in the midst of an acute myocardial infarction. The interventionalists should be aware that such minor complication may trigger massive thrombosis and no-reflow: this case suggests that manual aspiration thrombectomy with a catheter can also be considered as a very quick and handsfree technique to manage this complication during percutaneous coronary interventions. References [1] De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials. Eur Heart J 2008;29:3002–10. [2] Vlaar PJ, Svilaas T, Vogelzang M, Diercks GF, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan E, Suurmeijer AJ, Zijlstra F. A comparison of 2 thrombus aspiration devices with histopathological analysis of retrieved material in patients presenting with STsegment elevation myocardial infarction. JACC Cardiovasc Interv 2008; 1:258–64.
Air embolism caused by balloon rupture resolved by manual thrombectomy catheter aspiration Gianluca Rigatelli, Fabio Dell'Avvocata, Massimo Giordan, Paolo Cardaioli Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy Received 7 June 2010; revised 18 June 2010; accepted 24 June 2010
A 68-year-old lady with acute anterolateral myocardial infarction was referred to our center 3 h from symptom onset for emergent coronarography and percutaneous coronary intervention. Administration of abciximab was started immediately upon admission to the catheterization
laboratory. The coronary angiography revealed a paraostial occlusion of the left anterior descending (LAD) coronary artery (Fig. 1, Panel A) and normal left circumflex (LCx) and right coronary artery. Recanalization of the LAD was obtained after multiple dilation with a
Fig. 1. (Panel A) Emergent coronary angiography revealed a para-ostial occlusion of the left anterior descending coronary artery (LAD) and normal left circumflex coronary artery (LCx). (Panel B) Recanalization of LAD: a residual stenosis of the proximal LAD and its first diagonal branch was apparent. (Panel C) After stenting of the LAD, simultaneous kissing balloon inflation was performed: note (arrow) the rupture of the small 1.5×15-mm balloon with a mixed air/ contrast medium back flow presumably in the LCx and in the LAD (Panel D). (Panel E) Manual aspiration with a 6F Export catheter in both LCx and LAD with complete restoration of TIMI 3 blood flow in both vessels (Panel F). 1553-8389/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.carrev.2010.06.007
130
G. Rigatelli et al. / Cardiovascular Revascularization Medicine 12 (2011) 129–130
2.0×20-mm and a 2.0×30-mm angioplasty balloon (Panel B): the residual stenosis and ostial LAD and first diagonal branch were treated with a Vision 2.5×18-mm bare metal stent (Abbot Vascular, Abbott Park, IL, USA) and kissing balloon inflation was performed after wiring the diagonal branch. A Sprinter NC 2.75×12-mm balloon catheter for the LAD and a Sprinter Legend 1.5×15-mm balloon catheter (Medtronic, Minneapolis, MN, USA) for the diagonal branch were simultaneously inflated at 14 atm, but suddenly after the start of the inflation, the 1.5-mm balloon ruptured with back air embolism in the LCx and in the LAD (Panel C) resulting in complete left coronary artery no-reflow, cardiac arrest, and ventricular fibrillation (Panel D). The patient was immediately treated with cardiac massage, intravenous adrenalin, and ventilation which were all unsuccessful. Because of mechanical dissociation and no-reflow, while the IABP was set to emergent use, the LCx was wired and manual aspiration with a 6F Export thrombectomy catheter (Medtronic) was performed in both the LAD and LCx (Panel E) with complete and immediate TIMI 3 blood flow restoration and increase of blood pressure to 115/80 mmHg (Panel F). The patient was transferred in the ICU and was discharged after 7 days without other complications. Manual thrombectomy catheters were conceived for treating distal embolization and for retrieving the thrombus
during acute myocardial infarction. Recent studies have suggested a certain benefit from their use in acute myocardial infarction but with a variance in outcomes probably depending on specific structural differences of different devices [1,2]. Although the small amount of air in a 1.5-mm balloon was unlikely to cause massive air embolism, it could exacerbate a thrombotic hypercoagulable state in a patient already in the midst of an acute myocardial infarction. The interventionalists should be aware that such minor complication may trigger massive thrombosis and no-reflow: this case suggests that manual aspiration thrombectomy with a catheter can also be considered as a very quick and handsfree technique to manage this complication during percutaneous coronary interventions. References [1] De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials. Eur Heart J 2008;29:3002–10. [2] Vlaar PJ, Svilaas T, Vogelzang M, Diercks GF, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan E, Suurmeijer AJ, Zijlstra F. A comparison of 2 thrombus aspiration devices with histopathological analysis of retrieved material in patients presenting with STsegment elevation myocardial infarction. JACC Cardiovasc Interv 2008; 1:258–64.