Balloon Angioplasty Marks are Expelled.Where is the balloon?

J. Jorge Hakim Vista, MD, Carlos A. Garcia Hernandez MD Abelardo Mendez Vega, MD, Jose M. Calleja Bello, MD, Dr. Felix Martin Garzón, MD

Unidad de Terapia EndovascularHospital Civil « Dr. Luis F. Nachòn »

Universidad VeracruzanaXalapa , Veracruz, Mexico

Potential conflicts of interest

Speaker's name: Jorge Hakim Vista

I do not have any potential conflict of interest

Where is the balloon?

CASE:•Male Patient 80 years old : Diabetes type 2, Hypertension.•Unstable angina. •Echocardiogram: Ejection Fraction 45%, Antero-septal hypokinesia.•Normal Enzyme and creatinine.•Enoxoparin, Aspirin, Atorvastatin and Clopidogrel is indicated.

ANGIO RADIAL:

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LAD: Total occlusion, probably CTO.Intermedius Ramus: With diffuse lesion from the ostium, TIMI III flow.Circumflex: Developed, three significant lesions with TIMI III flow.Right Coronary Artery (RCA) is dominant and shows significant calcification and critical lesion bifurcated with acute marginal artery Medina 1-1-0 with TIMI III flow and collaterals grade II in middle and distal portions of the LADSYNTAX Score: 39 EuroSCORE: Standard 11 / Logistic 23.37%

Where is the balloon?

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• On RCA with 6 F JR guide-catheter, Choice PT 0.014” guide-wire progress was made without a problem.

• Because of the degree of arterial calcification, we used an appropriate balloon with flexible radiopaque marker of Tungsten (Mini Trek) 2.5x12mm which was inflated to 14 atm.

• At this time the balloon got broken, therefore coronary flow was completely blocked. When the balloon was removed, it came out incomplete.

• Dissection occurred at the site of dilatation and we noticed persistent of intracoronary marks.

Where is the balloon?

Where is the balloon?

• At the moment, we tried to pass another balloon, the position of the guide was lost outside the artery, there was persistent of intra-arterial marks and a slight improvement of distal coronary flow.

• Since the breakup of the balloon the patient presented hemodynamic instability and moderate angina.

• A Catheter GuideLiner 6F was used for greater support, guide wire PT Graphix is passed unsuccessfully, guide wire HT Progress 120 is inserted through microcatheter SuperCross also unsuccessfully. So the guide wire was removed.

Where is the balloon?

• We used a contrast-guided subintimal tracking and re-entry "rescue" (STAR-R) to locate the true intra-arterial spot , redirect the guide wire getting across the lesion and dilating it with a balloon (TREK)2.5x12mm.

• Because we were unable to penetrate through the dissection , implanted proximal to the lesion , 3.0x15mm Optima medicated stent , where GuideLiner was introduced.

1.-EuroIntervention 2011;6:106-1112.-Colombo A,. Treating chronic total occlusions usingsubintimal tracking and reentry: The STAR technique. CatheterCardiovasc Interv. 2005;64:407-11.

Where is the ballon?

• Then expands with balloons Ryujin Plus 1.5x15mm , 2.0x10 mm and 3.0x10 mm.

• Finally medicated stent implanted 2.5x15mm XIENCE V . The result with 3.0x10mm balloon to 14 Atm is optimized .

• TIMI III flow and preservation of the side branch was obtained.• The patient evolved satisfactorily.

Where is the ballon?

• Where is the balloon? Reviewing the first intracoronary guide wire used, we found out that the distal segment of the globe was tightly bound to the guide with loss of proximal mark of Tungsten, which was driven by a transverse rupture found microscopically. This caused a great confusion as we thought that throughout the whole procedure the broken balloon remained completely inside the artery.

Baloon

Proximal Distal

Where is the balloon?

Where is the balloon?