Inflated Balloon Trapped in Left Main Coronary

Dr. Rogelio V. TANGCO

Manila Doctors Hospital, Philippines

 

Background

A 63-year-old male, nonsmoker, with diabetic and positive family history of IHD, presented with exertional angina and dyspnoea. Stress testing with Sestamibi scan showed ischemia in the mid to distal LAD and RCA territories. 
Coronary angiogram revealed triple vessels CAD with a left main lesion near bifurcation, a near total LAD occlusion , a proximal LCx lesion, and a near total RCA occlusion proximally and a CTO lesion distally. There were prominent left to right and right to left collaterals. (Movie 1, Movie 2, Figure 1, Figure 2, Figure 3)

 

Procedure

Angioplasty and DES implantation of the long complex lesions in the RCA (Movie 3) and the near total LAD occlusion were performed uneventfully. (Movie 4) However, significant plaque shift to LCx ostium was seen. 

The LCx was then ballooned and subsequently a stent was deployed at LCx ostium. (Movie 5) However, after stent deployment, the stent balloon could not be retrieved back to the guiding catheter; reinflation was done after which balloon would not deflate. Vigorous tugging led to separation of the distal part of the balloon catheter from its proximal shaft, and the guidewire was pulled out of the left coronary. The inflated balloon was trapped in the left main. (Movie 6) Snaring of the distal shaft of the balloon catheter was done, and the trapped balloon within the left main was retrieved. (Movie 7) LCx flow was restored. (Movie 8) Follow up angiogram on the next day showed TIMI 3 flow in LAD and LCx without complication. (Movie 9)

Discussion

–   The preserved right to left collateral flow in this case enabled a hemodynamically stable emergency situation.

–   PCI device entrapment is rare and reported at a rate of only 0.4-1%

–   Entrapment of devices occurs most often in tortuous, angulated, or calcified lesions with sharp edges.

–   Factors leading to entrapment:

  • Lack of back up support of guiding catheters
  • Inadequate lesion preparation
  • Stiff and long stents

 

Non-surgical Remedy

–   Intracoronary nitroglycerin may assist in the reduction of arterial spasm

–   Undeflatable balloon – decrease the balloon viscosity by progressively diluting the contrast material within the balloon with saline + combined with rapid deflation

–   Deep intubation of the guiding catheter, along with the anchor system.