Circumferential rupture of an angioplasty balloon with detachment from the shaft: case report

Major Complications of Deep Venous Stenting

INTRODUCTION

Deep venous stent placement has developed into a primary treatment modality for venous obstruction in recent decades. Reported rates of complications are low in the literature and are based mainly on case reports and single-centre cohorts. Interventionalists performing these procedures must be aware of the occurrence of complications associated with stent placement to counsel patients adequately and promote avoidance through optimal procedural approach. This study aims to determine the incidence of serious complications associated with iliocaval and iliofemoral stent placement in a cohort of patients from 3 major tertiary deep venous referral centres.

METHODS

Data were collated from January 2014 to September 2023. The following major complications were included in the analysis: death, major bleeding requiring transfusion, massive pulmonary embolism, any complication which required endovascular or open surgical intervention, vessel rupture, acute kidney injury requiring dialysis, stent crushing, fracture, migration, involution or erosion.

RESULTS

One thousand eight hundred fourteen (1814) patients were treated for acute or chronic deep venous pathology during the 9-year study period. Sixty-one patients (3.3%) experienced a major stent-related complication. The most frequently reported complication was stent crushing (n = 18, 29.5%), followed by stent fracture (n = 10, 16.4%) and erosion of the stent through the vessel wall (n = 8, 13.1%). Death was a rare event (0.2%).

CONCLUSION

Deep venous stent placement is a safe procedure with low rates of major complications. It is incumbent upon operators to be aware of the risks associated with these procedures, however, rare, so that they may obtain fully informed consent from patients.

Balloon rupture with eversion during innominate vein angioplasty requiring surgical retrieval

Balloon rupture during angioplasty can with calcified or recalcitrant lesions. A 61-year-old woman presented with worsening arm and facial swelling. She had a history of left upper extremity thrombolysis and stenting of the innominate vein 6 years prior. Venography showed severe in-stent stenosis. After crossing the lesion, a 12-mm balloon was inflated, which ruptured at nominal pressure. The balloon became stuck and could not be moved over the wire even after retraction of the sheath. A limited surgical cutdown was performed, and the balloon and the wire were removed together. The ruptured balloon part was found to be everted and circumferentially wrapped around the wire, preventing the wire exchange. After cutting the everted portion of the balloon, the catheter was removed without losing wire access. A high-pressure balloon was subsequently used to treat the lesion successfully. Her symptoms had resolved on follow-up, and the stent remained patent after 6 months.

Entrapment of fractured balloon after angioplasty in an AV access using a covered stent

Fracture of the angioplasty balloon is a known complication during endovascular procedures in arteriovenous (AV) fistulas and grafts. We describe a case of a patient with end-stage renal disease (ESRD) on dialysis with a brachiocephalic AV fistula that had become dysfunctional. After a percutaneous angioplasty procedure during balloon withdrawal, a portion of the balloon fractured and separated due to the balloon being caught in the struts of a previously placed bare metal stent. A covered stent was used to contain the segment of the fractured balloon to the wall of the fistula. The use of a covered stent in jailing the fractured balloon to prevent further complications is not well described. This strategy may be implemented in some circumstances such as this case to avoid surgical interventions.

Rupture, Breakdown, and Pulmonary Artery Embolism of a Balloon Catheter Tip during Percutaneous Transluminal Angioplasty of Arteriovenous Fistula

Percutaneous transluminal angioplasty is a well-known treatment for arteriovenous fistula stenosis. Balloon rupture during endovascular procedures is a rare but possible complication. The bursting balloon itself does not cause a serious problem, but it can occasionally cause entrapment, especially in case of breakdown of the balloon catheter tip. Here, we present four cases of balloon rupture during angioplasty in the hemodialysis circuit. In three cases, the ruptured balloon catheter was removed by cutdown of access conduit, while in one case, tip of ruptured balloon catheter was migrated into the pulmonary artery and was removed surgically. The operator must attempt to reduce the risk of balloon rupture by gradually expanding the balloons under bursting pressure. If the balloon bursts, it should not be removed excessively and attempt should be made to remove it using endovascular techniques. Surgical removal is considered after careful evaluation of the condition of the balloon and vessel.

Retrieval strategy for ruptured balloon with circumferential tear during angioplasty for arteriovenous fistula in hemodialysis patients

INTRODUCTION

Balloon angioplasty is a common endovascular procedure. The balloon for angioplasty sometimes ruptures (incidence, 3.6%-10%), and it is constructed such that it ruptures in a longitudinal direction and complications related to rupture are rare. However, on rare occasions, retrieval is challenging, especially in the case of ruptures with a circumferential tear. There is no established method for retrieval and careful retrieval is required due to the risk of embolization by the residual balloon fragment.

TECHNIQUE

We describe two cases of balloon rupture in the transverse direction during percutaneous transluminal angioplasty for arteriovenous fistula in hemodialysis patients. In these cases, the balloon ruptured with a circumferential tear and dissected into two parts, and the tip edge remained in the vessel. We inserted an additional introducer at the side of the tip edge, caught the guidewire by a gooseneck snare, and hooked the residual balloon fragment. This also stabilized and increased the stiffness of the guidewire through the "pull-through technique." Then, we reintroduced the gooseneck snare to catch the residual balloon. We then inserted a cobra-head catheter from the first introducer and pushed the residual balloon. We finally retrieved the ruptured balloon by pulling back the gooseneck snare and pushing using the cobra-head catheter simultaneously.

RESULTS

We could retrieve the ruptured balloons successfully using this technique and percutaneous transluminal angioplasty was continued in both cases.

CONCLUSION

Our technique of retrieval may be suitable for cases of balloon rupture with a circumferential tear during percutaneous transluminal angioplasty. The technique enables less invasive retrieval and continuation of the percutaneous transluminal angioplasty thereafter.

Telescoping of sheaths-an easy technique to facilitate the removal of a stuck ruptured transluminal angioplasty balloon

Balloon rupture during angioplasty is an uncommon event. The ruptured balloon usually is removed through its introducer sheath without any problems. However, there may be occasions when a ruptured balloon cannot be withdrawn from an access. We describe a simple technique that can be used to extricate a stuck ruptured angioplasty balloon.

Balloon cinch deformity during angioplasty procedures: an indication for impending rupture

Percutaneous transluminal balloon angioplasty (PTA) is a commonly performed procedure for hemodialysis vascular access dysfunction including thrombosis. While PTA is generally safe, balloon rupture during the procedure is a potential complication. Because such a rupture can cause damage to the blood vessel, indication of an imminent balloon rupture might help avoid such a complication. This analysis reports on six PTA procedures that were complicated by balloon rupture. All cases demonstrated terminal (caudal/cranial) cinch deformation. There was a loss of sharp terminal tapering and its replacement with banana silhouette before the balloon rupture. Importantly, the contour deformation and balloon rupture occurred at a pressure that was lower than the rated burst pressure. The cinch deformity can be used as an indication for impending balloon rupture. We suggest deflation of balloons that demonstrate shape deformations to avoid vascular injury.

Change of the mechanical properties of two different balloon catheters with increasing numbers of cycles of resterilization

An increasing number of centers are reusing PTCA catheters even though manufacturers warrant single use only. This prospective bench laboratory trial addresses the quality of PTCA balloon catheters after up to three resterilization cycles in order to determine whether a larger trial is warranted to discern whether catheters should be reused. Forty PTCA catheters from two different manufacturers (nominal diameters 1.5 and 3.0 mm) were taken from the shelf. An independent institute tested mechanical properties such as burst pressure, nominal diameter, crossing profile, and balloon surface. The crossing profile increased by 22.5%-39.2% with no additional deterioration after repeated sterilizations. The nominal diameter either increased or decreased by a maximum of 47%. In all 1.5 mm balloons, the burst pressure remained above the manufacturers' values, whereas in the 3.0 mm balloons, the value dropped below the rated burst pressure in 40%-50% of the trials. In conclusion, in both catheter types analyzed, reuse was associated with a considerably worse quality, which puts in question their routine clinical use.

Contralateral loop snare removal of a ruptured and entrapped angioplasty balloon

We describe a technique that extracted a ruptured angioplasty balloon which had become entrapped by a calcified left common iliac artery stenosis. The balloon catheter had been advanced crossover from the right and could not be retracted directly into a sheath across the aortic bifurcation. Therefore, a guidewire was inserted through the balloon catheter and captured by a loop snare advanced from the left femoral artery. The loop snare was also used to free the balloon wings from the stenosis. The balloon was then pulled into a 10 Fr sheath and removed as a unit with the sheath.

Contralateral femoral vein removal of a circumferentially ruptured balloon-catheter following pulmonary artery angioplasty

While attempting to remove a circumferentially ruptured balloon following branch pulmonary artery angioplasty, the shaft of the catheter broke, leaving the distal portion of the balloon and catheter in the femoral vein but still on the exchange wire. We describe a method to retrieve the broken balloon catheter via the contralateral femoral vein.