Peripheral arterial lesions are usually longer than coronary artery lesions and require longer balloons and stents. Theoretically while advancing a long balloon in a long, high grade lesion with aggressive manipulation, the balloon can twist inside the lesion, but this has not been described before in the literature. Herein we are reporting a case where peripheral balloon (PB) twisted and appeared as a non-dilating lesion.
Peripheral arterial disease (PAD) is a common disease that affects millions of people worldwide. Endovascular procedures are more commonly performed to variety of lesions with different challenges. Peripheral balloons have been used for many years with reasonable results. Techical problems with PB’s such as rupture is well known but twist of the balloon has not been reported in the literature.
A 63 year old African American male with history of diabetes, hypertension, end stage renal disease on hemodialysis and left leg below knee amputation presented to our hospital with complaints of claudication and non-healing ulcer in the right 2nd toe. Ankle brachial index was non-diagnostic due to non-compressible vessels. Subsequently, patient underwent peripheral angiogram, and this showed heavy calcification in all of the vessels and mild disease in the right external iliac, common femoral, popliteal artery with distal chronic total occlusion (CTO) of anterior tibial artery, proximal CTO of posterior tibial artery. Peroneal artery had proximal and proximal–mid 80%–99% long, calcified stenosis ( Fig. 1 ), and it was providing blood supply to the foot via collaterals to distal anterior tibialis .To improve the flow in the foot, we planned intervention to peroneal artery. Initially, due to heavy calcification, orbital atherectomy (OA) was done using 1.25 mm Predator burr over the viper wire (Predator 360, viper wire, CSI Cardiovascular Systems, Inc., St. Paul, MN). For the balloon angioplasty (BA) a 2.5 × 80 m Nano cross (eV3 Inc. Plymouth, MN) was advanced, despite initial OA the balloon crossed the lesion with difficulty. We did not rotate the shaft of the balloon while advancing it through the lesion. During the inflation at 10 ATM (nominal pressure 10 ATM, rated burst pressure 14 ATM), we noticed a significant wasting in inflation in the mid short segment (dog boning) ( Fig. 2 ). The defect persisted in the same spot of the balloon during BA in a proximal location ( Fig. 3 ) suggestive of problem within the balloon rather than a non-dilatable lesion due to calcification. While we inflated the balloon at 13 ATM, the proximal part of the balloon had burst, but the distal part of the balloon stayed inflated, we had to use 50 cc syringe to aspirate the contrast and deflate the distal part of the balloon. After that, the partially deflated balloon was taken out. When we inflated the balloon outside the body, noticed a persistent lack of inflation in the mid shaft of the balloon with inflation in the distal, imperforated part. Post BA angiogram revealed less than 20% stenosis with good flow ( Fig. 4 ) and procedure ended with improvement of pulse in the exam. Clinical improvement was also seen in 1 month follow up with healing of the ulcer.