Inflate the Non-Inflatable, Deflate the Non-Deflatable
Dr. Joe Kin-Tong LEE
Case Summary
A 79-year-old lady complained of exertional angina. Coronary angiography revealed a subtotal occlusion at the mid-segment of RCA (Movie 1). After wiring and predilatation of the lesion, small focal dissection was noted at the predilatation spot expanding and extending distally during subsequent contrast injection (Movie 2). Two overlapping drug-eluting stents (2.0 x 30mm & 2.5 x 38mm) were implanted at the distal- and mid-segment of RCA respectively for dissection sealing. Subsequently, the indeflator failed to expand the balloon of the third stent (3.5 x 34mm) at the proximal RCA segment (Movie 3). Although the stent balloon could later fully inflate by multiple attempts at higher pressure (18 atmosphere), it then failed to deflate causing flow obstruction at the proximal RCA (Movie 4). Technique using tip-cut child catheters advancing along the guidewire and balloon shaft (hub removed) was attempted (Figure 1,Figure 2). A 6-French Guideliner (monorail technique) and a 4-French Heartrail II (over-the-wire technique) failed to reach out of the guiding catheter because of inadequate push-ability. Finally a 5-French Heartrail II child catheter could reach and puncture the balloon (Movie 5,Movie 6,Movie 7), then a 3.5 x 26mm stent was implanted at the ostium. The final angiographic result is shown in (Movie 8).
Conclusion
Coronary balloons may uncommonly become faulty, causing failure of inflation and/or deflation. Retrieval of balloon once it shows the first sign of inflation failure is preferred over repeated attempts of balloon inflation, which could lead to deflation failure, causing coronary obstruction. Five-French Heartrail II child catheter advancing over-the wire provides good push-ability to perform non-deflatable balloon puncture by tip-cut technique.
Nice case. We tend to believe and depend on the product quality but in actual fact, any product can be faulty or defective.
Importantly, we have to be vigilant and always look at the screen for an abnormal turn of events.
I once had a case of a promus stent not being able to be fully deployed in the proximal segment of a non-calcifeid LAD. Even ballooning could not remove the dog-bone effect of the stent. This led us to think that the stent maybe defective during manufacture.
Dear Dr rs,
Thank you very much for your comment.
Totally agree that operators should always be careful and vigilant. As said in our case conclusion, we propose to withdraw the balloon once it shows the first sign of inflation failure, so the subsequent problems could be avoided. The principle may not be applicable to your case of stent expansion problem, as you would not identify the issue until you have deflated the stent when it was too late to regret. Could you share how you dealt with the case?
Thank you.
Dr Joe Lee