Title:
A Stubborn Balloon Author: Subhabrata Dutta, David Sharman
Introduction:
Balloon-related complications during Percutaneous Coronary Intervention (PCI) represent a significant concern in interventional cardiology. These complications may include entrapment, rupture, dissection, perforation, and failure to deflate. Balloon entrapment or deflation failure, though rare, can be serious particularly in the context of heavily calcified lesions.
Clinical Case:
A 74-year-old woman presented with CCS Class III angina. Her cardiovascular risk factors included hypertension, type 2 diabetes mellitus, and hyperlipidemia. Diagnostic coronary angiography revealed severe, calcified coronary artery disease in the LAD and RCA. After multidisciplinary discussion, she was deemed unsuitable for coronary artery bypass grafting due to comorbidities and limited physiological reserve. Complex PCI was planned. Using right radial access, a Sion Blue wire was advanced to the LAD and exchanged for a Rota floppy wire. Rotational atherectomy was performed with a 1.5 mm burr. The LAD was sequentially pre-dilated with a 2.5 mm semi-compliant balloon, followed by a 3.0 mm non-compliant (NC) balloon and a 3.0 mm cutting balloon. A 3.0 × 38 mm drug-eluting stent (DES) was deployed in the proximal LAD. Intravascular ultrasound (IVUS) confirmed a proximal stent edge dissection extending into the left main stem (LMS). A decision was made to extend the stent proximally from LAD to LMS with a 4.0*23 DES. Post-dilatation was performed using a 4.0 mm NC in the LAD and a 5.0 mm NC in the LMS. During balloon withdrawal, the 5.0 mm NC balloon remained semi-deflated in the LMS. Gentle traction led to hypotube fracture, accompanied by chest pain, ischemic ECG changes, and hypotension. A 3.0 mm balloon positioned on the LCx wire was then used to trap the broken hypotube within the guide catheter. The entire guide catheter was withdrawn along with both wires, pulling the semi-deflated balloon from the LMS into the aorta. Attempts to remove the balloon via the radial sheath were unsuccessful, causing severe forearm pain. Multiple attempts to burst the balloon using Hornet 14 and CP12 wires failed. A 7 Fr femoral access was established, and a JR 4 guide catheter with a 30 mm EnSnare was used to capture the balloon. Despite applying the snare at various points, the balloon could not be deflated. Ultimately, the semi-inflated balloon was retrieved via the femoral access along with the sheath, and
hemostasis was achieved using manual compression of the femoral access site. The patient was monitored overnight and discharged after 48 hours, with a plan for staged RCA PCI.
Discussion:
Mechanisms of balloon entrapment or failure include:
- Severe calcified lesion: Entrapment caused by lesion recoil onto the balloon.
- Early pullback strangulation: Proximal balloon constriction by the guiding catheter.
- Hypotube damage: Mechanical failure of the balloon shaft or hypotube.
Management options reported in the literature include the buddy-balloon technique, subintimal plaque modification, and percutaneous retrieval with snares. In refractory cases, surgical extraction may be required. This case illustrates the importance of anticipating rare but serious complications during complex PCI and being prepared with advanced bailout strategies when conventional methods fail.