Cardiovasc Intervent Radiol (1996) 19:428-430

Case Reports

CardioVascular and Intervenfional Radiology �9 Springer-Verlag New York Inc. 1996

Contralateral Loop Snare Removal of a Ruptured and Entrapped Angioplasty Balloon

Michael A. Braun, 1'* Steven J. Smith, 2 Timothy N. Merrill 2 ~Department of Radiology/Olson Pavilion, Northwestern Memorial Hospital, 710 North Fairbanks Court, Chicago, IL 60611, USA 2Department of Radiology, La Grange Memorial Hospital, 5105 Willow Springs Road, La Grange, IL 60525, USA

Abstract We describe a technique that extracted a ruptured an- gioplasty balloon which had become entrapped by a calcified left common iliac artery stenosis. The balloon catheter had been advanced crossover from the right and could not be retracted directly into a sheath across the aortic bifurcation. Therefore, a guidewire was in- serted through the balloon catheter and captured by a loop snare advanced from the left femoral artery. The loop snare was also used to free the balloon wings from the stenosis. The balloon was then pulled into a 10 Fr sheath and removed as a unit with the sheath.

Key words: Arteries, i l iac--Transluminal angio- plasty--Stenosis or obstruction--Balloon rupture- - Retrieval

Balloon rupture during angioplasty or stricture dilation occurs even with high-pressure balloons. After balloon rupture, the catheter can usually be removed easily. Rarely, balloon rupture can be complicated by entrap- ment of the device, embolization of catheter fragments, or dislodgement of an intravascular stent.

Case Report

A 69-year-old white woman, status post quadruple coronary artery bypass graft, presented with severe left calf claudication and was admitted for left common iliac artery angioplasty. Angiography had demonstrated a focal, tight stenosis in the left common iliac artery and an eccentric 90% stenosis in the left conunon femoral artery (Fig. 1). The nonstenosed left iliac artery diameter measured 15 m m on cut film angiography.

* Present address: St. Mary ' s Hospital, Radiology Department, 2323 North Lake Drive, Milwaukee, WI 53201, USA

Correspondence to: M.A. Braun, M.D.

A right common femoral artery approach was used to avoid the left common femoral artery stenosis. A 7 Fr angioplasty catheter was used (Blue Max, Meditech, Boston, MA, USA) with a 12-ram-di- ameter by 4-cm-long balloon. The balloon catheter was passed over a wire into the stenotic left common iliac artery segment and the balloon was gently inflated with hand pressure. Minimal inflation produced pain and greater pressure was not used. After the third inflation, blood was observed in the syringe upon deflation. Removal of the balloon catheter was attempted but the balloon could not be dislodged from the angioplasty site. Forced deflation, traction, and torsion were unsuccessful in collapsing the balloon wings and dis- lodging the catheter. Various guidewires were inserted in unsuccess- ful attempts to push or pull the balloon free. Then the catheter hub was cut off and a long 9 Fr sheath was passed over the balloon catheter in an attempt to remove the entrapped device. Neither a 9 Fr nor a 10 Fr vascular sheath would advance beyond the proximal end of the balloon. Therefore we elected to remove the balloon catheter via the left common femoral artery, and a high left common femoral puncture was performed to avoid the mid-left common femoral artery stenosis. A 10 Fr sheath was placed into the left external iliac artery. A 15-mm nitinol gooseneck snare (Microvena Corporation, White Bear Lake, MN, USA) was used to capture a guidewire placed through the damaged balloon catheter and pull the wire through the left iliac sheath. The snare was then readvanced over the lodged bal- loon catheter and tightened to gather the wings of the balloon. Using a combination of pushing the balloon catheter and pulling on the loop snare, the balloon was dislodged from the angioplasty site. The bal- loon was delivered into the left external iliac artery sheath and pulled out as a unit with the sheath (Figs. 2, 3). The patient was then trans- ferred to surgery for suture of right and left common femoral artery puncture sites and left common femoral endarterectomy.

Analysis of the angioplasty catheter showed a puncture in the proximal one-third of the balloon and scratches along the balloon and distal shaft of the device. The vascular surgeon commented that the plaque removed from the left femoral artery stenosis was very sharp and calcified. The patient was free of left leg claudication at 6-month follow-up.

Discussion

Despite technical improvements in angioplasty catheter design, balloon rupture still occurs and may present problems, Balloon rupture was estimated to occur in 5 % - 1 0 % of angioplasty cases [1]. New balloon tech- nology allows for higher pressure balloon catheters

M.A. Braun et al.: Removal of Entrapped Angioplasty Balloon 429

Fig. 1. A Pre-angioplasty pelvic arteriogram demonstrating concentric stenosis involving the mid-left common iliac artery. B Left iliac arte- riogram demonstrating eccentric stenosis involving the mid-left com- mon femoral artery.

A

2

Fig. 2. Schematic diagram demonstrating contralateral extraction of the entrapped balloon. Top inset (A) shows spiculated stenosis rup- turing and entrapping the balloon. Bottom inset (B) shows snare col- lapsing balloon wings which frees the entrapped balloon. Large di- agram shows snare pulling the balloon off the stenosis into the con- tralateral sheath.

Fig. 3. Photograph of the snared and retrieved ruptured angioplasty balloon immediately following removal. The gooseneck snare encir- cled the midportion of the balloon gathering the wings into a folded configuration (arrow). This maneuver dislodged the trapped balloon. The snare was used to pull the balloon off the stenosis into the 10 Fr sheath (arrowhead).

making rupture less frequent during routine arterial an- gioplasty. However, angioplasty bal loon rupture can occur during dilatation of anastomotic strictures, cal- cified stenosis, mal ignant strictures, and during other nonvascular dilatation applications.

Two cases of complete detachment of an angio- plasty bal loon from the catheter shaft have been re- ported. Both balloons were early models of low profile balloons made by different manufacturers. Quinn and Hall in [2] describe a case of complete detachment of

430 M.A. Braun et al.: Removal of Entrapped Angioplasty Balloon

the angioplasty balloon from the catheter shaft. Shelby et al. [3] describe embolization o f a balloon due to cir- cumferential rupture during dilatation of the venous anastomosis of an arterial venous graft. Several reports have detailed detachment o f balloon-on-a-wire devices during coronary angioplasty [4].

Embolization o f air f rom rupture o f angioplasty bal- loons has been reported during coronary angioplasty. Kahn and Hartzler [5] reported five cases o f coronary air embolization due to a variety of mechanisms in- eluding balloon rupture. This resulted in a spectrum of symptomatology ranging f rom mild angina to full car- diac arrest. The symptoms tended to be transient, re- solving spontaneously in 5 - 1 0 min. There have been no reported air embolizations f rom balloon angioplasty in the peripheral vascular system. However, the poten- tial for this does exist in renal, mesenteric, and central nervous system applications o f balloon angioplasty.

A variety o f methods have been described to re- move the ruptured and entrapped angioplasty balloon catheter. Percutaneous methods should be attempted before surgical removal is contemplated unless there are signs of severe ischemia in the distal vascular bed. A loop snare can be used to refold the expanded balloon wings and can be precisely positioned on the torn bal- loon to gather the trapped segment. Loop snares are less bulky and more readily entrap a tubular-shaped foreign body than baskets. A smaller angioplasty bal- loon can be inflated next to the entrapped balloon frag- ments in order to dislodge the entrapped balloon [6]. I f efforts f rom an ipsilateral approach fail, a contralateral or a downstream approach should be chosen and may facilitate removal by providing a different vector o f force.

Most ruptured balloons tear longitudinally and can be fairly easily removed by twisting the catheter as it is withdrawn [7]. Alternatively, a ruptured balloon can be removed by gathering the expanded balloon wings within a vascular sheath that is advanced over the rup- tured balloon catheter [8]. More difficult ruptured bal- loon problems are posed by circumferential tears or entrapment of the expanded balloon within the stenosis [9]. When this problem occurs, it is best to determine the orientation o f the tear in order to determine the best

method for removing the ruptured balloon. Circumfer- entially torn balloons that cannot be withdrawn by trac- tion may be successfully advanced into a sheath and removed if there is the capability of accessing the vas- cular tree downstream f rom the stenosis. The circum- ferentially torn balloon can be treated as a foreign body and removed using snares or baskets. Heavily calcified stenoses have been reported to cause balloon rupture and entrapment [10]. Calcified atherosclerotic stenoses can have sha W spiculations which can cause pin-hole punctures o f balloons. This type o f lesion should be suspected when several balloons rupture in a pin-hole fashion at less than maximal inflation pressures. Cir- cumferential rupture of an angioplasty balloon with en- trapment of the distal half o f the inflated balloon within a calcified stenosis has been reported. This balloon was removed surgically [11].

R e f e r e n c e s

1. Angelini P (1990) Balloon catheter coronary angioplasty: Bal- loon rupture. (letter) Cathet Cardiovasc Diagn 20:150-151

2. Quinn SF, Hallin R (1990) Endovascular retention of a ruptured polyester balloon in femoral angioplasty. (letter) A JR 155:1141 - 1 1 4 2

3. Shelby JB Jr, Oliva VL, Tegtmeyer CJ (1992) Circumferential rupture of an angioplasty balloon with detachment from the shaft: Case report. Cardiovasc Intervent Radiol 15:113-116

4. Nukta E, Meier B, Urban P, Muller T (1990) Circumferential rupture and entrapment of a balloon-on-a-wire device during cor- onary angioplasty. Cathet Cardiovasc Diagn 20:123-125

5. Kahn JK, Hartzler GO (1990) The spectrum of symptomatic cor- onary air embolism during balloon angioplasty: Causes, conse- quences, and management. Am Heart J 119:1374-1377

6. Colombo A, Skinner JM (1990) Balloon entrapment in a coro- nary artery: Potential serious complications of balloon rupture. Cathet Cardiovasc Diagn 19:23-25

7. Gerlock AJ Jr, Regen DM, Shaft MI (1982) An examination of the physical characteristics leading to angioplasty balloon rup- ture. Radiology 144:421-422

8. Tegtmeyer CJ, Bezirdjian DR (1981) Removing the stuck, rup- tured angioplasty balloon catheter. Radiology 139:231-232

9. Yune HY, Klatte EC (1980) Circumferential tear of percutaneous transluminal angioplasty catheter balloon. AJR 135:395-396

10. Kahn JK, Hartzler GO (1990) Balloon rupture due to lesion mor- phology during coronary angioplasty. Cathet Cardiovasc Diagn 21:89-91

11. Kussmaul WG I/I, Marzo K, Tomaszewski J, DiSesa VJ (1993) Rupture and entrapment of a balloon catheter in the left anterior descending artery: Fluoroscopic appearance of impending bal- loon failure. Cathet Cardiovasc Diagn 28:256-259