Blocking Balloon Technique to Prevent Proximal Stent Migration After Stent Balloon Rupture

Coronary angioplasty balloons can rupture when treating calcified lesions, leading to complications such as perforation, dissection, and acute vessel closure.1Christopoulos G. Luna M. Brilakis E.S. The clinical implications of balloon rupture during cardiovascular interventions.J Invasive Cardiol. 2015; 27: E45-E50Google Scholar Unlike balloons, current generation drug-eluting stents are associated with very low rates of technical complications. We report a case of stent balloon rupture during primary percutaneous coronary intervention, causing acute vessel closure, rescued using the "blocking balloon" technique. A 25-year-old male e-cigarette user presented to the emergency department with chest pain and inferior ST segment elevation. Urgent coronary angiography revealed 100% occluded left circumflex artery (Figure 1A). Using a 6F 3.5 extra back-up guide catheter and an Asahi soft wire, the lesion was crossed, and balloon angioplasty was performed with a 3.0 × 15 mm semicompliant balloon, restoring antegrade flow. The chest pain and ST segment elevation resolved. A buddy wire was placed in the ramus branch for additional support. A 3.5 × 22 mm Onyx Frontier stent (Medtronic) was delivered and inflated to 14 atm. At this point, the operators noted an inability of the stent balloon to inflate and loss of pressure in the inflation device. We increased the inflation pressure to 28 atm, leading to partial deployment of the stent in its proximal segment and undeployed distal segment (Figure 1B). Contrast was seen in the distal vessel, confirming our suspicion of stent balloon rupture. The patient developed chest pain and ST segment elevation. Angiography showed acute vessel closure (Figure 1C). Removing the stent balloon pulled the partially deployed stent to the ostium of the circumflex (Figure 1D, Supplementary Video 1). To avoid inadvertently pulling the partially deployed stent into the left main, placement of a 3.0 × 8 mm compliant balloon in the ramus intermedius served as a "blocking balloon," facilitating complete retrieval of the ruptured stent balloon intact without proximal stent migration into the left main (Figure 1E, Supplementary Video 2). The ruptured stent balloon was noted to have a pinhole tear. The underexpanded stent was crossed and postdilated with a 2.0 × 8 mm and a 3.5 × 20 mm semicompliant balloon. Thrombolysis in myocardial infarction 3 flow was restored with resolution of the ST segment elevation (Figure 1F, Supplementary Video 3). Appropriate stent expansion was confirmed on intravascular ultrasound, with some longitudinal foreshortening in the proximal stent cells on fluoroscopy. Despite being pulled proximally, the stent was long enough, and an additional stent was not needed distally. Causes of stent balloon rupture include2Ayça B. Okuyan E. Şahin İ. Dinçkal M.H. Dislodgement of coronary stent due to rupture of stent balloon.Turk Kardiyol Dern Ars. 2015; 43: 93-94Crossref Scopus (2) Google Scholar (1) manufacturing defect, (2) calcific lesions, and (3) high-pressure inflation.3Sofidis G. Kartas A. Karagiannidis E. Stalikas N. Sianos G. A case of balloon rupture during coronary angioplasty: slow flow requiring swift action.Cureus. 2020; 12e9335Google Scholar Stent balloon rupture can cause dissection and/or distal air embolization, highlighting the importance of meticulous balloon preparation before delivery and deployment. Factory analysis of our stent balloon confirmed presence of a pinhole tear (images were not made available by manufacturer). Rarely, increasing inflation pressure of such a balloon beyond its instructions for use could result in coronary dissection due to a "jet effect"4Katayama T. Sakoda N. Yamamoto F. Ishizaki M. Iwasaki Y. Balloon rupture during coronary angioplasty causing dissection and intramural hematoma of the coronary artery; a case report.J Cardiol Cases. 2010; 1: e17-e20Abstract Full Text Full Text PDF Google Scholar; thus, this strategy should be pursued with caution. Removing the ruptured balloon may also result in stent displacement, as in our case. To our knowledge, this is the first reported case in the literature of a blocking balloon used to prevent stent migration during retrieval of a ruptured stent balloon. An alternate technique to a blocking balloon would be to cut the shaft of the stent balloon and advance a guide extension over it, telescoping the ruptured stent balloon. Another option would be to deploy or crush the displaced stent in a different coronary location (avoiding the left main bifurcation, as in our case). Emmanouil Brilakis received consulting/speaker honoraria from Abbott Vascular; is an associate editor for the American Heart Association, Circulation; received research support from Boston Scientific; is on the Board of Directors of the Cardiovascular Innovations Foundation; is a shareholder of Hippocrates LLC; and is XXXX for Amgen, Asahi Intecc, Biotronik, Cleerly Health, CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, MHI Ventures, Siemens, Stallion Medical, and Teleflex. Milan Ravishankar and Yashasvi Chugh reported no financial interests. This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.