Novel Bail-Out Use of Inari ClotTriever to Retrieve a Ruptured Balloon From the Venous System
Presenter
Adam Bykowski, DO, McLaren Macomb, macomb, MI
Adam Bykowski, DO1, Anila Rao2, Don Tait, DO3, Jason G Kaplan, MD4, Ryan Malek, D.O.5, Akarsh Parekh, MD2, Zeinab Saghir4, Varun Yelamanchili, MD4, Nicole Prentice-Gaytan5 and Jay Mohan, D.O., FSCAI4, (1)McLaren Macomb, macomb, MI, (2)McLaren Cardiovascular Institute, Mt. Clemens, MI, (3)McLaren Macomb, Mount Clemens, MI, (4)McLaren Cardiovascular Institute, Troy, MI, (5)McLaren Cardiovascular Institute, Mount Clemens, MI
Title
NOVEL BAIL OUT USE OF INARI CLOTTRIEVER TO RETRIEVE A RUPTURED BALLOON FROM THE VENOUS SYSTEM
Introduction
Aspiration of thrombus utilizing different thrombectomy devices are now being utilized by many cardiologists. However, due to their limited use, bail out techniques for managing complications are lacking. To date the use of the Inari ClotTriever has not been utilized for retrieval of retained foreign objects. We describe a case where ClotTriever was used to remove a retained balloon during a venous intervention.
Clinical Case
46 year old male presents for planned staged venous stenting. He was previously found to have a complete occlusion of his right iliofemoral system and was initially treated with venoplasty and thrombolysis. Imaging at that time demonstrated significant iliofemoral compression; however due to lack of a landing zone, stenting was not performed during initial intervention. Therefore the patient was placed on medical therapy with plans for repeat imaging and possible stent placement. Right popliteal vein approach was utilized with intravascular ultrasound (IVUS) guided imaging. IVUS confirmed compression of >60% throughout the right iliofemoral system due to venous fibrosis; however, a viable landing zone was now noted. Venoplasty was performed with an Atlas 16 x 40 mm balloon. During balloon inflation the balloon ruptured. The system was attempted to be removed; however, only the balloon delivery catheter was removed. Fluoroscopy demonstrated the balloon remained in the body near the femoral head. A gooseneck snare was used to snare the wire retaining the balloon. Unfortunately, upon removal of the snare, the balloon was not present. Venography demonstrated the balloon within the common femoral vein. Due to this, we elected to attempt to remove the balloon via ClotTriever. The Inari sheath was then placed and thrombectomy performed. Chronic thrombus was removed; however, the balloon was still retained. IVUS demonstrated the balloon still within the common femoral segment. Repeat passes were performed with direction of the catheter guided via IVUS. After the final pass, there was difficulty aspirating from the sheath so the suspicion was that the balloon had been pulled into the sheath. The sheath was removed, which demonstrated the balloon intact within the funnel of the ClotTriever sheath. The sheath was replaced and stenting of the right iliofemoral system was performed without incident. The sheath was removed and the patient was safely discharged the next day.
Discussion
Balloon rupture due to device malfunction is a complication with potentially devastating consequences. An interventionalist’s armamentarium for retrieval of retained foreign matter after these events can be pursued with multiple devices including snares, forceps, and fragment retrievers. One unique feature of this case was the inability to adequately visualize the balloon with fluoroscopy and the need for IVUS guided visualization given the lack of radiopaque markers on the balloon. To date, use of the Inari ClotTriever system has been relegated to thrombectomy for acute and chronic DVTs. In the case described, the ClotTriever was used as a bailout strategy to safely and effectively remove a retained balloon from the venous system.