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Loss and retrieval of a coronary angioplasty stent balloon
Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Cardiovascular Revascularization Medicine
Loss and retrieval of a coronary angioplasty stent balloon Peter Kayaert ⁎, Jeroen Sonck, Oscar Semeraro, Stijn Lochy, Hans Bonnier, Danny Schoors Universitair Ziekenhuis (UZ) Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
a r t i c l e
i n f o
Article history: Received 17 September 2012 Received in revised form 6 January 2013 Accepted 15 January 2013 Available online xxxx Keywords: Calcified lesions Loss of coronary device Retrieval maneuver
a b s t r a c t A case is presented in which a breakage of the coronary stent delivery catheter occurred as retrieval of the stent balloon was attempted after stent implantation. The broken distal balloon shaft with its stuck balloon was retrieved by controlled pulling on the guiding catheter in which a new balloon was inflated, thus trapping the distal shaft. The case underscores the importance of adequate lesion assessment and preparation. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous coronary intervention (PCI) has become a routine procedure. Experienced operators achieve very high success rates and complications are rare. But not all coronary lesions are equal. Some lesions are severely calcified and often a successful PCI is only possible after extensive lesion preparation with rotational atherectomy or excimer angioplasty. When not adequately prepared, stent deployment can be troublesome. A case is presented in which insufficient lesion preparation led to a life-threatening situation requiring a prompt and inventive solution.
2. Case report A 66 year old patient was referred with recurrent chest pain. Comorbidities included arterial hypertension, diabetes, dyslipidemia and smoking associated chronic obstructive pulmonary disease. 5 years previously he had undergone coronary artery bypass surgery (CABG) for stable angina with obstructive multivessel coronary artery disease. The distal left main coronary artery was severly narrowed and the right coronary artery (RCA) moderately stenotic. At surgery the left internal mammaria artery (LIMA) was used to bypass the left anterior descending artery (LAD) and three venous grafts for stenoses in a large intermediate branch (ramus intermedius, RI), the left circumflex artery (LCx) and the RCA. One year later the patient had a true posterior myocardial infarction due to occlusion of the LCx venous graft. At intervention, the graft was recanalized and stented with a drug-eluting stent (DES). ⁎ Corresponding author. E-mail address: [email protected] (P. Kayaert).
The venous graft on the RCA was also found to be occluded but the lesion in the RCA remained moderate and was left untreated. As the chest pain he now presented with was atypical, dobutamine stress echocardiography (DES) was performed. Its findings were highly suggestive of inducable inferior wall ischemia (chest pain and wall motion abnormalities). Global systolic left ventricular function at rest was slightly reduced. Given these results diagnostic coronary angiography was scheduled. The coronary angiogram (Fig. 1) showed patent grafts on LAD, LCx and RI but the RCA had a severe proximal stenosis and moderate disease distally. A decison was made to treat the RCA stenosis percutaneously. Since the RCA was significantly calcified (Fig. 1, arrows) upfront rotational atherectomy was indicated. To ensure optimal renal preparation, intervention was planned a few days later. At catheterisation, a 7 French sheath was placed in the right femoral artery. However, at that moment we were asked to free our room as soon as possible for an urgent VT ablation in a hemodynamically unstable young woman with persistent and drug refractory ventricular tachycardia. Because of time constraints, we skipped rotational atherectomy and proceeded immediately to conventional balloon predilation (Fig. 2). We placed an XBRCA guiding catheter (Cordis) for extra support and a Cruiser (Biotronik) workhorse wire and a Balance Heavyweight (Abbott) buddy wire in the RCA. We performed predilation of both the proximal and more distal stenosis using a semicompliant Pantera 2.5 × 10 mm balloon (Biotronik). Although the balloon was not completely expanded we were convinced that the plaque was sufficiently cracked and the lesion sufficiently modified to accommodate passage and deployment of the stent. A 3.0 × 14 mm drug-eluting Biomatrix stent (Biosensors) was advanced with the intention to deploy it in the more distal lesion.
1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.01.003
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003
2
P. Kayaert et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
Fig. 1. Baseline coronary angiogram of the RCA in left anterior oblique (LAO) and right anterior oblique (RAO) view. The arrows indicate the calcifications in the vessel wall.
However, we were unable to pass the proximal lesion with the result that the stent became trapped in the proximal lesion. In order to avoid stripping off the undeployed stent from the balloon we avoided forceful attempts to retrieve it and deployed the stent. In this way we hoped the stenosis would be sufficiently dilated to pass the residual stenosis with a non compliant balloon thus allowing further lesion dilation. Upon pullback of the stent delivery system, only the balloon shaft was retrieved and fluoroscopy revealed that the incompletely deflated stent balloon was still trapped within the stent, thus limiting coronary flow. The ST-segments became raised and the patient developed persistent chest pain. By advancing a coronary wire next to the balloon, we attempted to dislodge the balloon to enable snaring and retrieval [1]. Several wires
with different characteristics (Streamer (Biotronik), Fielder XT and MiracleBros 6 (both Asahi)) were used, but none passed or dislodged the balloon. The surgical team was asked to stand by. We then realised that perhaps there was still a portion of the distal part of the balloon shaft in the guiding catheter. If we were able to trap this part, we might be able to retrieve the balloon. A comparison of the length of the retrieved shaft with the length of an intact Biomatrix balloon shaft revealed that the shaft was broken at the level of the exit port of the wire. We assumed that a snare would easily slip off the shaft material and other techniques (such as using biopsy equipment) would require retraction of the guiding catheter. Therefore we attempted another technique to trap the distal balloon shaft. First, the guiding catheter
Fig. 2. Procedure part 1: Initial predilations and proximal stent implantation. Upon trying to retrieve the stent balloon, the balloon shaft broke and the balloon was stuck. The partially deflated balloon was uncrossable and was eventually retrieved by a controlled pulling on the guiding catheter in which a new balloon was inflated, trapping the distal balloon shaft.
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003
P. Kayaert et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
3
Fig. 3. Procedure part 2: Recannulation of RCA followed by stenting of proximal and mid RCA (see text for details).
was dislodged slightly out of the RCA ostium (to avoid ostial dissection during pulling on the guiding catheter) and then a large and long angioplasty balloon (Pantera 4.0 × 30 mm, Biotronik) was inflated at 20 atm in the distal tip of the guiding catheter, thereby fixating the distal balloon shaft. Then we pulled carefully on the guiding catheter itself. Using this approach we were able to retrieve the stuck balloon and the guiding catheter as a whole through the radial sheath. To proceed we recannulated the RCA with an Amplatz Left 1 guiding catheter (Cordis) to provide even more support (Fig. 3). Unfortunately this resulted in ostial dissection. To deal with this we stented the ostium with a Biomatrix 3.5 × 23 mm stent and then were able to dilate the RCA further. We used small semicompliant balloons to pass and inflate the still incompletely deployed first stent. A bigger non-compliant Pantera Leo 3.0 × 8 balloon inflated at high pressure (28 atm) was then used to apposition it correctly. Distal to this stent, two complimentary Biomatrix (3.0 × 18 mm and 3.0 × 14 mm) stents were placed (the latter to cover distal edge dissection). After final high pressure postdilations an acceptable result was achieved. The patient was discharged from the cath lab pain free and went home the next day. He remains asymptomatic 1 year later. 3. Discussion We present a case in which a stent balloon was not easily retrieved after stent implantation. The pullback of the balloon shaft resulted in a fracture of the shaft. This situation caused prolonged myocardial ischemia and was life-threatening. A special maneuver was employed to quickly retrieve the trapped balloon. The procedure was then completed successfully. Three main lessons are to be learned from the case. Firstly, in calcified lesions, adequate preparation is necessary to allow proper stent positioning and inflation. In this case predilation using semicompliant balloons was insufficient and non-compliant balloons or even upfront rotational atherectomy should have been used. The decision to omit these maneuvers in the interest of time turned out to be a mistake and probably prolonged the procedure. In our opinion it is better to postpone a case in favor of a more urgent one than to cut corners and deviate from the planned strategy.
Secondly, stent delivery systems can break within the guiding catheter although it has only been reported a few times [1–4]. The fact that it was first impossible to advance the delivery system is highly suggestive that it entered a still very narrow and calcified lesion, in which both stent balloon and stent became stuck. Due to application of excessive pushing and pulling forces, the shaft finally broke at the exit port of the wire. This segment, by nature of its design, is perhaps more prone to fracture and rupture. Thirdly, a stuck balloon can be retrieved by a trapping–pulling maneuver. The technique has been reported previously [2–4]. It was successful in our case but should only be used if surgical backup is available as one can imagine that the technique could cause severe damage to the artery. 4. Conclusions Success in percutaneous coronary interventions depends upon many factors but adequate lesion assessment and preparation are extremely important. Once again it was demonstrated in this complication case. When time constraints preclude the necessary lesion preparation, a case should be delayed. A coronary stent balloon and its shaft can be damaged by advancing the stent into an insufficiently prepared lesion. If this results in rupture of the balloon shaft, the latter and its attached balloon can be retrieved by the trapping maneuver we describe. However surgical cover for such an attempt is mandatory. References [1] Madronero JL, Hein F, Bergbauer M. Removal of a ruptured, detached, and entrapped angioplasty balloon after coronary stenting. J Invasive Cardiol 2000;12:102–4. [2] Trehan V, Mukhopadhyay S, Yusuf J, C Ramgasetty U, Mukherjee S, Arora R. Intracoronary fracture and embolization of a coronary angioplasty balloon catheter: retrieval by a simple technique. Catheter Cardiovasc Interv 2003;58:473–7. [3] Wani SP, Rha SW, Park JY, Poddar KL, Wang L, Ramasamy S, et al. A novel technique for retrieval of a drug-eluting stent after catheter break and stent loss. Korean Circ J 2010 Aug;40:405–9. [4] Kharge J, Sreekumar P, Swamy K, Bharatha A, Ramegowda RT, Nanjappa MC. Balloon-assisted retrieval of a broken stent-delivery system. Tex Heart Inst J 2012;39(5):644–6.
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003
Contents lists available at SciVerse ScienceDirect
Cardiovascular Revascularization Medicine
Loss and retrieval of a coronary angioplasty stent balloon Peter Kayaert ⁎, Jeroen Sonck, Oscar Semeraro, Stijn Lochy, Hans Bonnier, Danny Schoors Universitair Ziekenhuis (UZ) Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
a r t i c l e
i n f o
Article history: Received 17 September 2012 Received in revised form 6 January 2013 Accepted 15 January 2013 Available online xxxx Keywords: Calcified lesions Loss of coronary device Retrieval maneuver
a b s t r a c t A case is presented in which a breakage of the coronary stent delivery catheter occurred as retrieval of the stent balloon was attempted after stent implantation. The broken distal balloon shaft with its stuck balloon was retrieved by controlled pulling on the guiding catheter in which a new balloon was inflated, thus trapping the distal shaft. The case underscores the importance of adequate lesion assessment and preparation. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous coronary intervention (PCI) has become a routine procedure. Experienced operators achieve very high success rates and complications are rare. But not all coronary lesions are equal. Some lesions are severely calcified and often a successful PCI is only possible after extensive lesion preparation with rotational atherectomy or excimer angioplasty. When not adequately prepared, stent deployment can be troublesome. A case is presented in which insufficient lesion preparation led to a life-threatening situation requiring a prompt and inventive solution.
2. Case report A 66 year old patient was referred with recurrent chest pain. Comorbidities included arterial hypertension, diabetes, dyslipidemia and smoking associated chronic obstructive pulmonary disease. 5 years previously he had undergone coronary artery bypass surgery (CABG) for stable angina with obstructive multivessel coronary artery disease. The distal left main coronary artery was severly narrowed and the right coronary artery (RCA) moderately stenotic. At surgery the left internal mammaria artery (LIMA) was used to bypass the left anterior descending artery (LAD) and three venous grafts for stenoses in a large intermediate branch (ramus intermedius, RI), the left circumflex artery (LCx) and the RCA. One year later the patient had a true posterior myocardial infarction due to occlusion of the LCx venous graft. At intervention, the graft was recanalized and stented with a drug-eluting stent (DES). ⁎ Corresponding author. E-mail address: [email protected] (P. Kayaert).
The venous graft on the RCA was also found to be occluded but the lesion in the RCA remained moderate and was left untreated. As the chest pain he now presented with was atypical, dobutamine stress echocardiography (DES) was performed. Its findings were highly suggestive of inducable inferior wall ischemia (chest pain and wall motion abnormalities). Global systolic left ventricular function at rest was slightly reduced. Given these results diagnostic coronary angiography was scheduled. The coronary angiogram (Fig. 1) showed patent grafts on LAD, LCx and RI but the RCA had a severe proximal stenosis and moderate disease distally. A decison was made to treat the RCA stenosis percutaneously. Since the RCA was significantly calcified (Fig. 1, arrows) upfront rotational atherectomy was indicated. To ensure optimal renal preparation, intervention was planned a few days later. At catheterisation, a 7 French sheath was placed in the right femoral artery. However, at that moment we were asked to free our room as soon as possible for an urgent VT ablation in a hemodynamically unstable young woman with persistent and drug refractory ventricular tachycardia. Because of time constraints, we skipped rotational atherectomy and proceeded immediately to conventional balloon predilation (Fig. 2). We placed an XBRCA guiding catheter (Cordis) for extra support and a Cruiser (Biotronik) workhorse wire and a Balance Heavyweight (Abbott) buddy wire in the RCA. We performed predilation of both the proximal and more distal stenosis using a semicompliant Pantera 2.5 × 10 mm balloon (Biotronik). Although the balloon was not completely expanded we were convinced that the plaque was sufficiently cracked and the lesion sufficiently modified to accommodate passage and deployment of the stent. A 3.0 × 14 mm drug-eluting Biomatrix stent (Biosensors) was advanced with the intention to deploy it in the more distal lesion.
1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.01.003
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003
2
P. Kayaert et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
Fig. 1. Baseline coronary angiogram of the RCA in left anterior oblique (LAO) and right anterior oblique (RAO) view. The arrows indicate the calcifications in the vessel wall.
However, we were unable to pass the proximal lesion with the result that the stent became trapped in the proximal lesion. In order to avoid stripping off the undeployed stent from the balloon we avoided forceful attempts to retrieve it and deployed the stent. In this way we hoped the stenosis would be sufficiently dilated to pass the residual stenosis with a non compliant balloon thus allowing further lesion dilation. Upon pullback of the stent delivery system, only the balloon shaft was retrieved and fluoroscopy revealed that the incompletely deflated stent balloon was still trapped within the stent, thus limiting coronary flow. The ST-segments became raised and the patient developed persistent chest pain. By advancing a coronary wire next to the balloon, we attempted to dislodge the balloon to enable snaring and retrieval [1]. Several wires
with different characteristics (Streamer (Biotronik), Fielder XT and MiracleBros 6 (both Asahi)) were used, but none passed or dislodged the balloon. The surgical team was asked to stand by. We then realised that perhaps there was still a portion of the distal part of the balloon shaft in the guiding catheter. If we were able to trap this part, we might be able to retrieve the balloon. A comparison of the length of the retrieved shaft with the length of an intact Biomatrix balloon shaft revealed that the shaft was broken at the level of the exit port of the wire. We assumed that a snare would easily slip off the shaft material and other techniques (such as using biopsy equipment) would require retraction of the guiding catheter. Therefore we attempted another technique to trap the distal balloon shaft. First, the guiding catheter
Fig. 2. Procedure part 1: Initial predilations and proximal stent implantation. Upon trying to retrieve the stent balloon, the balloon shaft broke and the balloon was stuck. The partially deflated balloon was uncrossable and was eventually retrieved by a controlled pulling on the guiding catheter in which a new balloon was inflated, trapping the distal balloon shaft.
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003
P. Kayaert et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
3
Fig. 3. Procedure part 2: Recannulation of RCA followed by stenting of proximal and mid RCA (see text for details).
was dislodged slightly out of the RCA ostium (to avoid ostial dissection during pulling on the guiding catheter) and then a large and long angioplasty balloon (Pantera 4.0 × 30 mm, Biotronik) was inflated at 20 atm in the distal tip of the guiding catheter, thereby fixating the distal balloon shaft. Then we pulled carefully on the guiding catheter itself. Using this approach we were able to retrieve the stuck balloon and the guiding catheter as a whole through the radial sheath. To proceed we recannulated the RCA with an Amplatz Left 1 guiding catheter (Cordis) to provide even more support (Fig. 3). Unfortunately this resulted in ostial dissection. To deal with this we stented the ostium with a Biomatrix 3.5 × 23 mm stent and then were able to dilate the RCA further. We used small semicompliant balloons to pass and inflate the still incompletely deployed first stent. A bigger non-compliant Pantera Leo 3.0 × 8 balloon inflated at high pressure (28 atm) was then used to apposition it correctly. Distal to this stent, two complimentary Biomatrix (3.0 × 18 mm and 3.0 × 14 mm) stents were placed (the latter to cover distal edge dissection). After final high pressure postdilations an acceptable result was achieved. The patient was discharged from the cath lab pain free and went home the next day. He remains asymptomatic 1 year later. 3. Discussion We present a case in which a stent balloon was not easily retrieved after stent implantation. The pullback of the balloon shaft resulted in a fracture of the shaft. This situation caused prolonged myocardial ischemia and was life-threatening. A special maneuver was employed to quickly retrieve the trapped balloon. The procedure was then completed successfully. Three main lessons are to be learned from the case. Firstly, in calcified lesions, adequate preparation is necessary to allow proper stent positioning and inflation. In this case predilation using semicompliant balloons was insufficient and non-compliant balloons or even upfront rotational atherectomy should have been used. The decision to omit these maneuvers in the interest of time turned out to be a mistake and probably prolonged the procedure. In our opinion it is better to postpone a case in favor of a more urgent one than to cut corners and deviate from the planned strategy.
Secondly, stent delivery systems can break within the guiding catheter although it has only been reported a few times [1–4]. The fact that it was first impossible to advance the delivery system is highly suggestive that it entered a still very narrow and calcified lesion, in which both stent balloon and stent became stuck. Due to application of excessive pushing and pulling forces, the shaft finally broke at the exit port of the wire. This segment, by nature of its design, is perhaps more prone to fracture and rupture. Thirdly, a stuck balloon can be retrieved by a trapping–pulling maneuver. The technique has been reported previously [2–4]. It was successful in our case but should only be used if surgical backup is available as one can imagine that the technique could cause severe damage to the artery. 4. Conclusions Success in percutaneous coronary interventions depends upon many factors but adequate lesion assessment and preparation are extremely important. Once again it was demonstrated in this complication case. When time constraints preclude the necessary lesion preparation, a case should be delayed. A coronary stent balloon and its shaft can be damaged by advancing the stent into an insufficiently prepared lesion. If this results in rupture of the balloon shaft, the latter and its attached balloon can be retrieved by the trapping maneuver we describe. However surgical cover for such an attempt is mandatory. References [1] Madronero JL, Hein F, Bergbauer M. Removal of a ruptured, detached, and entrapped angioplasty balloon after coronary stenting. J Invasive Cardiol 2000;12:102–4. [2] Trehan V, Mukhopadhyay S, Yusuf J, C Ramgasetty U, Mukherjee S, Arora R. Intracoronary fracture and embolization of a coronary angioplasty balloon catheter: retrieval by a simple technique. Catheter Cardiovasc Interv 2003;58:473–7. [3] Wani SP, Rha SW, Park JY, Poddar KL, Wang L, Ramasamy S, et al. A novel technique for retrieval of a drug-eluting stent after catheter break and stent loss. Korean Circ J 2010 Aug;40:405–9. [4] Kharge J, Sreekumar P, Swamy K, Bharatha A, Ramegowda RT, Nanjappa MC. Balloon-assisted retrieval of a broken stent-delivery system. Tex Heart Inst J 2012;39(5):644–6.
Please cite this article as: Kayaert P, et al, Loss and retrieval of a coronary angioplasty stent balloon, Cardiovasc Revasc Med (2013), http:// dx.doi.org/10.1016/j.carrev.2013.01.003