Suggested Technique

A Novel Approach for Percutaneous Retrieval of an Entrapped, Broken Balloon Catheter During Primary Percutaneous Coronary Intervention

Nadim Shah, MBChB, DMedSc, FRACP, Ayman Al-Sibaie, MD, PhD, Sam Benny, BSc, Mohamed Aboalela Elberry, MBBS, Geili Abdalla, MBBS, MD, Fahad Baslaib, MD, Cardiology Department, Rashid Hospital, Dubai, United Arab Emirates

Nadim Shah, MBChB, DMedSc, FRACP, Ayman Al-Sibaie, MD, PhD, Sam Benny, BSc, Mohamed Aboalela Elberry, MBBS, Geili Abdalla, MBBS, MD, Fahad Baslaib, MD, Cardiology Department, Rashid Hospital, Dubai, United Arab Emirates

Balloon and stent catheters are designed and usually robust enough for their use in percutaneous coronary intervention (PCI). Often they have to withstand relatively high longitudinal forces as they are introduced in and out of epicardial coronary arteries. Balloons are often used to measure the length of lesions to estimate lesion length and hence, choose appropriately sized stents. This practice is usually performed without complication. It is, however, possible for the balloon to become entrapped within the coronary artery, leading to fracture and breakage of the catheter shaft.1 This is a rare but dangerous complication that requires patience and pre-defined management strategies in order to avoid morbidity or worse, mortality. Here, we discuss such a case and ultimately describe the successful strategy used to retrieve a broken and entrapped balloon catheter.

Case Report

A 39-year-old male presented with chest pain of two days duration consistent with myocardial ischemia. The maximum intensity of the pain, however, was two hours prior to presentation. The patient was hypertensive and a current smoker. No remarkable findings were detected on physical examination. An electrocardiogram (ECG) revealed ST-segment elevation in the anterior leads and he was transferred for urgent coronary angiography. The peak troponin T was 8019 ng/L.

Coronary angiography was undertaken via the right radial approach, which revealed occlusion of the proximal left anterior descending (LAD) and proximal left circumflex arteries (LCx) (Figure 1). The right coronary artery (RCA) was free of significant stenosis (Figure 2). Primary PCI was completed for the LCx with the deployment of a 3.5 x 38 mm drug-eluting stent (DES) via an extra backup (EBU) 3.0 guiding catheter (Figure 3). The LCx was treated first, as there was anticipation of ostial LAD stenting with stent protrusion to the left main coronary artery.

Primary PCI for the proximal LAD was undertaken with the deployment of a 3.5 x 24 mm DES (Figure 4). Following the stent deployment, however, a moderate to severe stenosis of the mid LAD became apparent (Figure 4). To aid in measuring the length of the stenosis in the mid LAD, the 3.5 x 24 mm DES stent balloon was reintroduced to the LAD (Figure 5). On attempting to withdraw the stent balloon, the tip of the balloon catheter broke and the balloon was entrapped within the proximal LAD stent (Figure 6). An initial attempt was made to trap the broken balloon catheter, which was still within the guiding catheter, with a 1.25 x 10 mm balloon, but this only served to embolize the broken balloon catheter further into the LAD (Figure 7). 

In addition, the broken balloon catheter shaft had now prolapsed out of the guiding catheter and the filament was now in the right subclavian artery (Figure 8). 

Multiple unsuccessful attempts were made to snare the broken balloon catheter using Goose Neck snares (Medtronic). A Captura mini biopsy forceps (Cook Medical) was then introduced via the right brachial artery (Figures 9-10). The short length of this device prohibited it from continuing via the radial route.

The forceps was advanced via an 8 French (Fr) sheath and a 7 Fr Judkins Right 4 (JR 4) guiding catheter, which was shortened, as the standard length was too long to accommodate the mini biopsy forceps. This allowed capture and removal of the broken balloon catheter (Figure 11-13). Subsequent selective coronary angiography of the LAD and LCx demonstrated TIMI-3 flow. Conservative management of the mid LAD stenosis was pursued in the first instance, with a view to proceeding if ongoing symptoms appeared. Echocardiography performed following PCI demonstrated moderate reduction of left ventricular systolic function. The patient was discharged in a stable condition four days later and was asymptomatic during subsequent follow-up in outpatient clinic three months later. 

Discussion

The literature on this topic is lacking, but there are reports of Goose Neck snares being utilized to remove disrupted balloon catheters.2 A brief review of the literature, however, did not reveal the particular device used in this case and so the description provided here appears to be novel. 

In retrospect, the complication encountered could have been avoided if the stent balloon catheter was not reintroduced to the LAD. This is common practice and is often valuable to aid in measurement of the length of stenosis, thereby allowing appropriately sized stents to be deployed. Rather than reintroduction of the stent balloon, the balloon could also have been advanced immediately post deployment of the proximal LAD stent to the mid LAD. Without retrieving the stent balloon first, however, an adequate angiogram was not possible and the severity of the mid LAD lesion would have been underappreciated.

Alternate methods of measuring the lesion include using the length of platinum in the distal tip of the guide wire or using an alternate workhorse guide wire such as the ATW marker wire. (Cordis, A Cardinal Health company). The advantage of the ATW maker wire is the inclusion of four radiopaque markers that are spaced 10 mm apart.

Entrapment likely occurred when the balloon was being withdrawn from the mid LAD and caught in the proximal LAD stent. Post dilatation of the proximal LAD stent, thereby improving apposition, may have avoided the entrapment. The fact that the balloon had been pre inflated likely also increased the risk of it catching in the stent. It is also possible that the shaft of the balloon catheter was weakened during deployment of the stent and the further stress of reintroduction caused it to break. On retrieval, multiple angulations were appreciated on the distal part of the balloon catheter (Figure 12). 

The successful resolution of this potentially dangerous complication was only possible due to collaboration between cardiology, interventional radiology, and gastroenterology staff. The patient was relatively stable throughout the procedure with no hemodynamic instability, but he did have symptoms that were effectively controlled with analgesia and sedation. An interventional radiologist performed the retrieval procedure and the gastroenterology team provided the Captura mini biopsy forceps. This case highlights the importance of a multidisciplinary team approach and the importance of collaboration when facing any complication.

Conclusion

A novel approach using a Captura mini biopsy forceps to retrieve a broken and entrapped balloon catheter was successful in a young patient presenting for primary PCI. 

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Dr. Nadim Shah, Cardiology Department, Rashid Hospital, Dubai, United Arab Emirates, tel. +971 4 219 1000 or email nadim.shah@gmail.com

References
  1. Desai CK, Petrasko M, Steffen K, et al. Retained coronary balloon requiring emergent open surgical retrieval: an uncommon complication requiring individualized management strategies. Methodist Debakey Cardiovasc J. 2019; 15: 81-85.
  2. Bartus S, Kameczura T, Chyrchel M, et al. Rescue removal of disrupted balloon catheter from right coronary artery and aortic arch. Kardiol Pol. 2013; 71: 772-774.