27.

3
How to approach balloon
entrapment/fracture

Emmanouil S. Brilakis, MD, PhD

 Acute Complications of PCI

Cardiac
Non-cardiac
Coronary Non-coronary

1. Hypotension 1. Vascular access

Acute vessel closure
2. Myocardial infarction complications
1. Dissection
3. Arrhythmias 2. Thromboembolic
• Coronary
Perforation 4. Tamponade complications
• Aortocoronary
• main vessel 3. Contrast-related
2. Thrombosis • distal vessel complications
3. Embolization • collateral (nephropathy, allergies)
• Thrombus
4. Radiation injury
• Plaque
• Air
4. Side branch occlusion
5. Spasm Equipment
6. Pseudolesion loss/entrapment
7. Equipment entrapment
8. Intramural hematoma
9. Aortic dissection
 Balloon entrapment/fracture: causes

Balloon entrapment Balloon shaft fracture

1. Balloon rupture 1. Kinking of balloon shaft
2. Balloon failure to
deflate
3. Balloon interaction with
prior stent
Failure to deflate: causes

Leibundgut G. et al. Case Rep Cardiol 2018:6252809

Fractured covered
stent shaft

CTOmanual.org: case 131

 Balloon entrapment/fracture: prevention

Balloon entrapment Balloon shaft fracture

1. Primary atherectomy 1. Discard balloons with
for severely calcified kinked shaft
lesions
2. Avoid very high-
pressure balloon
inflation
Balloon entrapment/fracture: treatment
Balloon entrapment/fracture: treatment
 4 × 15 mm DES

stiff end of 0.018″ SV‐5 wire

Failure to deflate
Slight kink in stent balloon shaft
Tried indeflator filled with normal saline
Stiff end of 0.014 inch Stabilizer wire failed to puncture balloon

Girish MP et al. Catheter Cardiovasc Interv 2011;77:58-61

Successful balloon deflation and balloon
retrieval after puncture with back end of
0.018 inch guidewire

Girish MP et al. Catheter Cardiovasc Interv 2011;77:58-61

Balloon entrapment/fracture: treatment
Chang WT et al. J Formos Med Assoc 2015;114:1135-9
Chang WT et al. J Formos Med Assoc 2015;114:1135-9
Chang WT et al. J Formos Med Assoc 2015;114:1135-9
Balloon entrapment/fracture: treatment
Jiménez JL et al. Catheter Cardiovasc Interv 2017;90:773-776
Jiménez JL et al. Catheter Cardiovasc Interv 2017;90:773-776
 Manual of non-CTO Coronary Interventions
Case 8: Angiosculpt fracture

Broken
New
balloon
Angiosculpt
segment
balloon
Emmanouil S. Brilakis, MD, PhD
Peter Tajti, MD
Actual length
of fractured
shaft
Minneapolis Heart Institute
Proximal
edge of the
shafts
Proximal LAD and distal RCA lesions
Attempt to deliver 3.5
mm AngioSculpt
balloon using distal
anchor

Failed
 Fractured
AngioSculpt shaft
What came out…
Now what?
Angiosculpt fragment by IVUS
Trapper balloon
advancement
 Broken
AngioSculpt
withdrawal with
trapping balloon
 Entrapped broken
AngioSculpt in aorta
 Successful
withdrawal of
broken particle

Broken
New
balloon
Angiosculpt
segment
balloon

Actual length
of fractured
shaft

Proximal
edge of the
shafts
Further 3.5 and 4.0 balloon inflations failed
 Procedure time: 200 min
Contrast volume: 300 ml
Fluoroscopy time: 54.9 min
AK radiation dose: 5.651 Gray

Final result

Procedure stopped
due to high radiation
dose
Balloon entrapment/fracture: treatment
A B C

D E

Iturbe JM et al. J Invas Cardiol 2012:24:215-221

Balloon fragment covered with stent

Christopoulos G et al. J Invas Cardiol 2015;27;E45-E50

Balloon entrapment/fracture: treatment