Surgical Removal of Broken and Inflated Percutaneous Transluminal Coronary Angioplasty Balloon Catheter: Role of Transesophageal Echocardiography.

An entrapment and breakage of coronary angioplasty catheter during coronary intervention is a rare but serious complication. Percutaneous transluminal coronary angioplasty (PTCA) catheter got entrapped and broken inside the left anterior descending artery (LAD) in a 58-year-old male patient. The whole length of the PTCA catheter was retrieved through an arteriotomy incision in LAD along with reversed saphenous vein graft to LAD, under cardiopulmonary bypass and cardioplegic arrest. We discuss here the various percutaneous retrieval techniques and surgical management of entrapped broken PTCA catheter and also the role of transesophageal echocardiography intraoperatively. Copyright:

INTRODUCTION

Percutaneous transluminal coronary angioplasty (PTCA) even though is a safe procedure, its increasing application in managing complex coronary lesions has led to increase in incidents such as entrapment, fracture, and dislodgment. The management of entrapped and broken PTCA catheter can be interventional/surgical or conservative management depending on the location and clinical condition of the patient.

CASE PRESENTATION

A 58-year-old male patient, known case of hepatocellular carcinoma with lung metastasis on tablet. sorafenib 200 mg for 6 months, presented with complaints of chest pain and breathing difficulty. Chest pain was associated with vomiting and left arm numbness. He was hemodynamically stable with normal echocardiography study and electrocardiogram. His troponin T-high sensitive was elevated and was planned for coronary angiogram (CAG).

CAG showed left main 80% stenosed, left anterior descending artery (LAD) – diffusely diseased with multiple tandem tight lesions, and distal LAD was occluded and filled from collaterals. Left circumflex artery (LCX) – dominant, two tandem 90% stenosis in proximal LCX, and major obtuse marginal. Right coronary artery – totally occluded and distal vessel was seen filling from early arising right ventricular branch [Figure 1 and Video 1]. As he had associated comorbidities with Child–Pugh Class A Prognosis, it was planned to proceed with percutaneous coronary intervention (PCI) rather than coronary artery bypass graft surgery. During PCI, flow in LCX was successfully obtained, however, after inflating the LAD stent, there was difficulty in balloon deflation and was unable to pull out the balloon catheter. Various percutaneous maneuvers attempted to retrieve the balloon were unsuccessful, and finally, the catheter got broken with inflated balloon occluding the LAD flow. Snaring technique to pull the broken catheter was unsuccessful. The patient developed angina and hypotension. Injection noradrenaline was started at 0.05 mcg/kg/min, and emergency coronary arteriotomy was planned for balloon retrieval and revascularization of LAD with saphenous grafting. The patient was induced as per our institutional protocol, and transesophageal echocardiography (TEE) probe (iE33 Philips with X7-2T probe) was introduced without any difficulty.

Figure 1

Left anterior oblique view showing inflated percutaneous transluminal coronary angioplasty balloon (yellow arrow) occluding the left anterior descending artery flow

TEE examination showed mildly dilated left ventricle (LV), ejection fraction 35%, and severely hypokinetic anterior and anteroseptal LV wall. TEE also showed the broken catheter extending from the ascending aorta to descending thoracic aorta (DTA) [Figures 2–5 and Videos 2–5], with broken end of the catheter in DTA [Figures 6, 7 and Videos 6, 7]. Under moderate hypothermia in cardiopulmonary bypass (CPB) with cold-blood hyperkalemic antegrade cardioplegic arrest, arteriotomy was done in midportion of the LAD and through the arteriotomy site, the stent along with the PTCA catheter was retrieved by gentle traction [Figure 8]. Aortic cross-clamp was released, and CPB machine switched off for a brief period of time during retrieval of the catheter. Reversed saphenous vein grafting was done to LAD. The patient was weaned off CPB without difficulty, and the postoperative course was uneventful.

Figure 2

Midesophageal ascending aorta short-axis view showing broken catheter. Right pulmonary artery

Figure 5

Upper esophageal arch of aorta short-axis view showing broken catheter

Figure 6

Midesophageal descending thoracic aorta short-axis view showing broken catheter

Figure 7

Midesophageal descending thoracic aorta short-axis view showing broken catheter

Figure 8

Broken percutaneous transluminal coronary angioplasty catheter retrieved via left anterior descending artery arteriotomy

Midesophageal ascending aorta long-axis view showing broken catheter

Upper esophageal arch of aorta long-axis view showing broken catheter

DISCUSSION

During PCI, the incidence of catheter-related problems such as fracture, dislodgment, and entrapment constitutes around 0.1%–0.2%.[1] Reasons for broken catheter can be due to patient-related factors (calcified or tortuous vessel and complex lesion), operator-related factors (inadequate predilatation, excessive pushing, and frequent reuse of hardware), or device-related factors (manufacturing defects).[2] Failure to remove retained fragments could lead to thrombus formation, acute embolization, and myocardial infarction.[3] Retrieval technique of the retained broken fragment depends on patients hemodynamics, operator skill, and availability of retrieval devices. Retrieval techniques can be percutaneous retrieval, surgical removal, and conservative management.

The various percutaneous retrieval techniques include double- or triple-wire technique, deep wedging of guiding catheter and traction of the system, retrieval using balloon inflation technique, retrieval by snare loop, retrieval using microcatheter, for example, Tornus catheter extraction with bioptome.[4] Percutaneous retrieval techniques can be unpredictable, difficult, and dangerous.

Our patient developed angina and hypotension while attempting to retrieve percutaneously; hence, emergency surgical extraction of the broken catheter was done. Surgical extraction can be done either by direct coronary arteriotomy or aortotomy combined with bypass grafting.[5]

The role of TEE in surgical extraction is to define the extension and locating the distal end of the catheter or guidewire. The author could demonstrate the catheter extending till the proximal part of DTA in the present case. The presence of catheter or guidewire in the ascending aorta can be mistaken for aortic dissection, and hence, careful evaluation in TEE is needed in multiple views.

There are even reports where guidewire or components of PTCA lodged in chronically occluded coronary arteries or distal segments have been managed conservatively.[6] These patients were treated with systemic anticoagulation and anti-platelets with close follow-up and referring to early surgical management if ischemic events are encountered.

CONCLUSION

PTCA guidewire and balloon catheter entrapment is a rare complication. Cardiologist, cardiac surgeon, and cardiac anesthesiologist should be aware of the various techniques for retrieval. TEE helps in defining the extension of the retained segment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.