Abstract
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.
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. Co-morbidities 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). 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. 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 . 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 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.
