Balloon rupture during coronary angioplasty

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.

Association of the long fluoroscopy time with factors in contemporary primary percutaneous coronary interventions

BACKGROUND

Since the long fluoroscopy time in primary PCI for ST-segment elevation myocardial infarction (STEMI) could be an indicator of delayed reperfusion, it should be important to recognize which types of lesions require longer fluoroscopy-time in primary PCI. The purpose of this study was to investigate the association of the long fluoroscopy-time with clinical factors in primary percutaneous coronary interventions (PCI).

METHODS

A total of 539 patients who underwent primary PCI were divided into the conventional fluoroscopy-time group (Q1-Q4: n = 434) and the long fluoroscopy-time group (Q5: n = 105) according to the quintile of the total fluoroscopy time in primary PCI. Univariate and multivariate logistic regression analyses were performed to find associations between clinical variables and the long fluoroscopy-time.

RESULTS

In univariate logistic regression analysis, prevalence of diabetes mellitus, hemodialysis, and previous CABG were significantly associated with the long fluoroscopy-time. In addition, complex lesion characteristics such as lesion length, lesion angle, tortuosity, and calcification were associated with the long fluoroscopy-time. In multivariable logistic regression analysis, lesion length [per 10 mm incremental: odds ratio (OR) 1.751, 95% confidence interval (CI) 1.397-2.195, P<0.001], moderate-excessive tortuosity (vs. mild tortuosity: OR 4.006, 95% CI 1.498-10.715, P = 0.006), and moderate to severe calcification (vs. none-mild calcification: OR 1.865, 95% CI 1.107-3.140, P = 0.019) were significantly associated with the long fluoroscopy-time.

CONCLUSIONS

In primary PCI for STEMI, diffuse long lesion, tortuosity, and moderate-severe calcification were associated with the long fluoroscopy-time. These complex features require special attention to reduce reperfusion time in primary PCI.

A Case of Balloon Rupture During Coronary Angioplasty: Slow Flow Requiring Swift Action

We describe the case of a middle-aged man undergoing three-vessel coronary angioplasty due to unstable angina. Attempt to predilate a calcified lesion in the left circumflex artery with a semi-compliant balloon, inflated above the rated burst pressure, resulted in balloon rupture. Subsequently, the patient developed ST elevations and became hemodynamically unstable; slow flow in the index vessel was noted. The complication was managed with vasopressor and respiratory support, plus forceful injections of warm saline. Thrombolysis in myocardial infarction (TIMI)-3 flow was eventually restored, and the rest of the procedure was completed uneventfully. Following retrieval of the device, a longitudinal tear in the balloon was observed. This mode of rupture is considered to be safer, when compared to circumferential or pin-hole rupture. Rupture can occur when a balloon is aggressively inflated above nominal pressures and against calcific lesions. The ensuing micro- and macrovascular complications, including slow-flow, no-reflow, vessel dissection or perforation, and intramural hematoma, may induce myocardial ischemia and ultimately cardiogenic shock, malignant arrhythmias, and cardiac arrest. Management should be swift, and relies on supportive measures, depending on the degree of complications caused by the rupture.

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.

Critical Pressure for Arterial Wall Rupture in Major Human Cerebral Arteries

Background and Purpose—

Intracranial bleeding is linked to hemodynamic stress factors, such as hypertension. However, there are no studies that tested the breaking pressure of normal large cerebral arteries in humans.

Methods—

The brains of 10 cadavers (age, 47±14 years; 9 men) were harvested within 48 hours postmortem for 31 segments of the main intracranial arteries. After careful microsurgical preparation, the vessels were pressurized with saline and observed until they ruptured.

Results—

Vessel diameters averaged 2.6±0.3 mm (range, 1.2–4.3 mm). The average rupture pressure was 2.21±0.59 atm (range, 1.13–4.3 atm) and decreased with age at −0.025 atm/y ( R 2 =40%; P <0.0002). The maximum diameter distention at rupture was 30±9% (13%–52%), which also decreased with age (−0.5%/y; R 2 =78%; P <0.00001). Neither the rupture pressure nor the maximum distention showed significant dependence on the resting vessel diameter. No significant dependencies were found on the vessel origin, vascular configuration, direction of the rupture, or the presence of minor coexisting pathology.

Conclusions—

Human cerebral arterial wall breaks only at extremely high intravascular pressures, exceeding several times the highest observed systolic blood pressure, even accounting for age trends. Systolic hypertension alone may not be sufficient to cause intracranial hemorrhage, and there may be additional contributing factors.

Carotid artery stenting for calcified lesions

BACKGROUND AND PURPOSE

Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions.

MATERIALS AND METHODS

Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded.

RESULTS

The mean arc of calcification was 201.1 +/- 72.3 degrees (range, 76-352 degrees ), and the mean of the total calcification volume was 154.9 +/- 35.4 mm(3) (range, 92-2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis < or =30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure.

CONCLUSION

CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.

Removal of fractured balloon catheter using another balloon inflation in coronary artery: case report

In this report, a novel management to the problem of a fractured balloon catheter which is a very rarely seen complication and has not yet been reported in the nature as in our case during percutaneous transluminal coronary interventions is presented. We inserted a second balloon catheter to the space between the previous fractured balloon and the wall of right coronary artery, and then by inflating the second balloon catheter at low pressure, the guide-wire of fractured balloon catheter and the second sound balloon catheter gently and cautiously removed together into the guiding catheter. Subsequently, the whole system was taken out of the body without complication.

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.

Repeated balloon rupture during coronary stenting due to a calcified lesion: an intravascular ultrasound study

We describe a patient in whom balloon rupture occurred three times during inflation in a stent with restenosis in the left anterior descending artery. The cause of rupture was detected by intravascular ultrasound: a calcified ridge that protruded between the stent struts in the distal stent body.

Coronary dissection due to overdilatation of an elastic membrane of the multi-link stent delivery system caused by balloon rupture

A 65-year-old male with unstable angina underwent coronary angiography, which revealed a significant stenotic lesion in the right coronary artery. This narrowing was subsequently treated with the Multi-Link stent. During the balloon inflation associated with stent deployment, balloon rupture occurred and resulted in overdilatation of an elastic membrane in the stent delivery system. This, in turn, resulted in coronary dissection, which required treatment with further stenting.

Use of intravascular ultrasound in evaluating repeated balloon rupture during coronary stenting

Balloon rupture during coronary angioplasty is a well-recognized complication of PTCA. Coronary angiography commonly fails to elicit the cause of balloon perforation. We present a case with multiple balloon rupture during additional high-pressure inflations of a Palmaz-Schatz stent where intravascular ultrasound was useful in revealing a calcified lesion protruding through the struts of the stent.

Multiple balloon rupture during coronary angioplasty. A case report

The authors report a case of coronary angioplasty of the left anterior descending artery complicated by multiple balloon rupture. Various balloon types including polyethylene terephthalate and PE 600 (ACS) ruptured at low atmospheric pressure. During balloon rupture, a septal side branch was dissected with severe intimal staining. The authors postulate that a particular lesion morphology was responsible for balloon rupture. Approaches to such lesions using alternative coronary angioplasty techniques and newer technologies are discussed.

Circumferential balloon rupture and catheter fracture due to entrapment in a calcified coronary stenosis

We report a case of coronary angioplasty balloon rupture and catheter fracture within a calcified lesion, requiring emergency coronary bypass surgery. The entrapped catheter could not be removed at surgery. This case re-emphasizes the hazards associated with angioplasty of calcified lesions.

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.

Inflated balloon entrapped in a calcified coronary stenosis

Balloon angioplasty in calcified coronary lesions may have a decreased success rate and an increased incidence of complications. Previous cases have been reported on the phenomena of catheter or wire entrapment, but this report highlights a new problem in association with a calcified stenoses. This case lead to the unusual problem of the inflated balloon being entrapped within the lesion while the distal portion of the balloon remained inflated even after balloon deflation.

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

Rapidly evolving angioplasty balloon techniques need continual evaluation for the type or frequency of balloon-related complications. We recently encountered a case where a new narrow shaft polyethylene terephthalate balloon completely separated from the catheter following circumferential rupture. The balloon was successfully retrieved using grasping forceps and a basket. Patterns of balloon rupture and subsequent management are discussed. Problems of this type were more frequent in the early days of balloon angioplasty, but have since become rare. Close surveillance of new low profile balloons is recommended to determine whether this represents an isolated occurrence or a return to the earlier experience.

Circumferential rupture and entrapment of a balloon-on-a-wire device during coronary angioplasty

While attempting to dilate a distal lesion in a right coronary artery, using a balloon-on-a-wire catheter, circumferential balloon rupture occurred with temporary entrapment of the balloon in the stenosis. The balloon was retrieved, and the dilatation completed, using an over-the-wire balloon catheter.

Pinhole balloon rupture during coronary angioplasty causing rupture of the coronary artery

We report a case of pinhole balloon rupture during percutaneous transluminal coronary angioplasty using one of the newer catheters. Pinhole balloon rupture resulted in rupture and occlusion of the vessel being dilated.

Balloon inflation following injection of contrast material through the distal lumen of the USCI balloon catheter

We report on four patients in whom we observed inflation of the balloon following injection of contrast material into the distal lumen during percutaneous transluminal coronary angioplasty. This is a rare technical problem. However, inadvertent balloon inflation may cause transient occlusion of the proximal coronary artery and in one case was associated with acute occlusion of a vessel that had been dilated. Management involves prompt deflation of the balloon.