Case Report A Rare and Serious Unforeseen Complication...

Case ReportA Rare and Serious Unforeseen Complication ofCutting Balloon Angioplasty

Praveen Vemula1 Jagadeesh K Kalavakunta1 George S Abela1 and Milind Karve2

1 Department of Medicine Division of Cardiology Michigan State University College of Human Medicine East Lansing MI USA2Division of Cardiology Sparrow Health System Lansing MI USA

Correspondence should be addressed to Praveen Vemula vemulaprmsuedu

Received 18 November 2013 Accepted 19 February 2014 Published 23 March 2014

Academic Editors T Kasai and K Shimada

Copyright copy 2014 Praveen Vemula et alThis is an open access article distributed under theCreativeCommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Cutting balloon angioplasty (CBA) is one of the adept ways of treating ldquoin-stent restenosisrdquo Various complications related to cuttingballoon angioplasty have been reported including arterial rupture delayed perforation and fracture of microsurgical blades Herewe report a very unusual and inadvertent extraction of a stent previously deployed in the ramus intermedius coronary branch by acutting balloon catheter This required repeat stenting of the same site for an underlying dissection Even though stent extractionis a rare complication it can be serious due to dissection perforation and closure of the artery Physicians performing coronaryartery interventions would need to be aware of this rare and serious complication especially if any difficulty is encountered whilewithdrawing the cutting balloon Therefore after removal cutting balloon should be examined thoroughly for possible stentdislodgment or extraction when used for ldquoin-stent restenosisrdquo

1 Introduction

In-stent restenosis is one of the important causes of failureof previously successful percutaneous intervention (PCI)Restenosis occurs secondary to neointimal tissue prolifera-tion which is mediated by inflammation following arterialinjury [1 2] Drug eluting stents (DES) have greatly reducedrates of restenosis compared to that of bare metal stents [3ndash5] However there are no clear guidelines for appropriatetherapy of DES restenosis probably due to low incidenceof restenosis and its varied etiology [6] Cutting balloonangioplasty (CBA) is one of the safest cost effective and adeptways of treating in-stent stenosis [7ndash9] Cutting balloon has 3-4 microsurgical blades attached to its surface longitudinallyInflation of the balloonwill result in cutting of atheroscleroticplaqueThis creates controlled injury and potentially reducesinflammation Various complications related to CBA havebeen reported including arterial rupture perforation andfracture of microsurgical blades [10ndash12] In this case reportwe present an unforeseen complication of CBA in which apreviously deployed stent is inadvertently extracted alongwith the cutting balloon

2 Case Presentation

A 71-year-old Caucasian male patient with past medicalhistory of coronary artery disease hypertension congestiveheart failure and stroke presented with the chief complaintof left arm pain and dyspnea He had similar symptoms fivemonths prior to the current admission at which time heunderwent PCI with an Ion (Boston Scientific) DES stent(25 times 24mm) placement to a moderate caliber ramus inter-medius coronary artery with an 85 long segment stenosisDuring this admission the patient presented with left armpain which started while he was driving and was associatedwith dyspnea both worsening with minimal exertion andrelieved with sublingual nitroglycerine

Cardiovascular examination revealed a grade IIVImidsystolic murmur best heard in the left midclavicularline in fourth intercostal space No heaves thrills jugu-lar venous distension or carotid bruits were appreciatedRespiratory examination revealed fine crackles at the lungbases bilaterally The rest of the physical examination wasunremarkable Chest X-ray demonstrated cardiomegaly withmild pulmonary vascular congestion Electrocardiogram

Hindawi Publishing CorporationCase Reports in CardiologyVolume 2014 Article ID 246784 4 pageshttpdxdoiorg1011552014246784

2 Case Reports in Cardiology

(a) (b)

Figure 1 Flextome cutting balloon with extended blades (a) Extracted stent (b)

(ECG) demonstrated normal sinus rhythm with a rightbundle branch block and an old anterior and inferior infarctLaboratory data on admission demonstrated a troponin-I of 005 ngmL (normal reference range lt 002) andBNP gt 5000 pgmL BUN of 20mgdL and creatinine of15mgdL

The patient was admitted to the cardiac step-down unitwith the diagnosis of unstable angina His cardiac biomark-ers trended upward but were in an indeterminate rangeDiagnostic cardiac catheterization was performed coronaryangiography demonstrated focal in-stent restenosis (70ndash80)prior to a bend in the mid ramus intermedius artery Thedecision was made to use CBA for the in-stent stenosisWith a 6 Fr Voda 35 guiding catheter (Boston Scientific) a25 times 10mmcutting balloon (Flextome Boston Scientific) wasintroduced to site of ldquoin-stent stenosisrdquo over 001410158401015840 BMW(balanced middle weight) guide wire and slowly inflatedand deflated Three inflations were performed (7 7 and10 atmospheres) However while withdrawing the cuttingballoon some difficulty was noted Eventually the cuttingballoon was slowly removed via the guiding catheter Thecutting balloonwas carefully examined andwenoticed a stentoverlying the cutting balloon It appeared that the previouslydeployed stent 5 months earlier had been pulled out alongwith cutting balloon (Figure 1)

Repeat coronary angiography demonstrated a dissectionat the previously stented site of the ramus branch Afterseveral attempts a 001410158401015840 whisper wire successfully crossedthe arterial segment Predilations were performed with 25 times20 mini Trek compliant balloon and then 25 times 24mmIon (Boston Scientific) DES stent was deployed at 12 atmo-spheres Poststent deployment angiogram was performedwith and without the wire following the administrationof intracoronary nitroglycerine This showed 0 residualstenosis and TIMI III flow without dissection (Figure 2)Patient was returned to the floor in a stable conditionand has remained asymptomatic on the follow-up clinicvisits

3 Discussion

Cutting balloon angioplasty is one of the common interven-tions for ldquoin-stent restenosisrdquo It has practical benefits overpercutaneous transluminal coronary angioplasty (PTCA)Cutting balloon has an advantage of better anchorage toslippery hyperplastic tissue over traditional PTCA balloonsAlso the expanded blades of a cutting balloon can incisethe tissue up to the stent cage This provides an advantageof deep incision of hyperplastic tissue Restenosis cuttingballoon evaluation trial (RESCUT) clearly demonstratesthese benefits of CBA over PTCA [13] Other techniques (ieexcimer laser atherectomy mechanical atherectomy radia-tion catheter and rotational atherectomy) are also availableto treat in-stent stenosis These techniques are uncommonsecondary to the cost involved in equipment and specializedtraining

Since CBA is a widely used technique it is important tounderstand various complications that may arise during andafter this procedure Various complications related to CBAhave been reported including arterial rupture delayed per-foration stent strut avulsion and fracture of microsurgicalblades [10ndash12] However very few cases have been reportedregarding inadvertent stent extraction as a complicationof CBA In our case we report inadvertent extraction oframus intermedius stent by an entrapped cutting ballooncausing arterial dissection at previously stented site Harband Ling reported on the extraction of a stent deployed atthe coronary ostium that was entrapped by the passage ofa guide wire through protruding stent struts [14] SimilarlyAlmeda and Billhardt reported that a distal RCA stent wasfound attached to microtomes of a cutting balloon uponwithdrawal [15] Another case reported entrapment of stentsecondary to blade fracture leading to stent extraction andacute occlusion of the coronary artery [16] In our case thereason for entrapment is not clear We carefully reviewedthe previous stent angiograms which revealed appropriatesize and deployment Most likely the anatomical bend inthe ramus intermedius artery as well as the entrapment of

Case Reports in Cardiology 3

(a) (b)

(c) (d)

Figure 2 (a) RAO (right anterior oblique) caudal viewof the left coronary artery system showing a significant lesion (arrowhead) in the ramusintermedius branch at the bend in the proximal to mid portion (b) Cutting balloon angioplasty (CBA) and post CBA angiogram (c) withdissection (arrow head) (d) Postintervention angiogram showed TIMI III flow without any dissection (TIMI thrombolysis in myocardialinfarction)

the cutting balloon blades in the stent struts maybe togethercaused the stent extraction A repeat angiogram after the stentextraction suggested a dissection at the previously stented siterequiring restenting of the ramus intermedius with a DES

4 Conclusion

To our knowledge stent extraction is a very rare complica-tion of CBA In our case the inadvertent stent extractionby a cutting balloon also resulted in arterial dissectionAlthough it is a rare complication stent extraction cancause a serious coronary artery injury Physicians performingcoronary artery interventions should be aware of this rare andserious complication especially if they encounter difficultywhile withdrawing the cutting balloon After removal cuttingballoons should be inspected thoroughly for an extractedstent

Conflict of Interests

George S Abela is a speaker for Merck

References

[1] R Hoffmann G S Mintz G R Dussaillant et al ldquoPatternsand mechanisms of in-stent restenosis a serial intravascularultrasound studyrdquo Circulation vol 94 no 6 pp 1247ndash12541996

[2] R Kornowski M K Hong F O Tio O Bramwell H Wu andM B Leon ldquoIn-stent restenosis contributions of inflammatoryresponses and arterial injury to neointimal hyperplasiardquo Journalof the American College of Cardiology vol 31 no 1 pp 224ndash2301998

[3] G W Stone S G Ellis D A Cox et al ldquoA polymer-basedpaclitaxel-eluting stent in patientswith coronary artery diseaserdquoTheNewEngland Journal ofMedicine vol 350 no 3 pp 221ndash2312004

[4] J W Moses M B Leon J J Popma et al ldquoSirolimus-elutingstents versus standard stents in patients with stenosis in a nativecoronary arteryrdquoTheNew England Journal of Medicine vol 349no 14 pp 1315ndash1323 2003

[5] G D Dangas B E Claessen A Caixeta E A Sanidas G SMintz and R Mehran ldquoIn-stent restenosis in the drug-elutingstent erardquo Journal of the American College of Cardiology vol 56no 23 pp 1897ndash1907 2010


[6] H-G Song D-W Park Y-H Kim et al ldquoRandomized trial ofoptimal treatment strategies for in-stent restenosis after drug-eluting stent implantationrdquo Journal of the American College ofCardiology vol 59 no 12 pp 1093ndash1100 2012

[7] M Adamian A Colombo C Briguori et al ldquoCutting bal-loon angioplasty for the treatment of in-stent restenosis amatched comparison with rotational atherectomy additionalstent implantation and balloon angioplastyrdquo Journal of theAmerican College of Cardiology vol 38 no 3 pp 672ndash679 2001

[8] A S Kurbaan R A Foale and U Sigwart ldquoCutting balloonangioplasty for in-stent restenosisrdquo Catheterization and Cardio-vascular Interventions vol 50 pp 480ndash483 2000


[10] K K Haridas M Vijayakumar K Viveka T Rajesh and N KMahesh ldquoFracture of cutting balloonmicrosurgical blade insidecoronary artery during angioplasty of tough restenotic lesion acase reportrdquo Catheterization and Cardiovascular Interventionsvol 58 no 2 pp 199ndash201 2003

[11] E N Brountzos N Ptohis H Triantafyllidi et al ldquoRenal arteryrupture following cutting balloon angioplasty for fibromusculardysplasia a case reportrdquo Cases Journal vol 2 no 9 article 88812009

[12] T Maruo S Yasuda and S Miyazaki ldquoDelayed appearance ofcoronary artery perforation following cutting balloon angio-plastyrdquo Catheterization and Cardiovascular Interventions vol57 no 4 pp 529ndash531 2002

[13] R Albiero S Silber C Di Mario et al ldquoCutting balloon versusconventional balloon angioplasty for the treatment of in-stentrestenosis results of the restenosis cutting balloon evaluationtrial (RESCUT)rdquo Journal of the American College of Cardiologyvol 43 no 6 pp 943ndash949 2004

[14] T S Harb and F S Ling ldquoInadvertent stent extraction sixmonths after implantation by an entrapped cutting balloonrdquoCatheterization and Cardiovascular Interventions vol 53 no 3pp 415ndash419 2001

[15] F Q Almeda and R A Billhardt ldquoInadvertent intracoronarystent extraction 10 months after implantation complicating cut-ting balloon angioplasty for in-stent restenosisrdquo CardiovascularRadiation Medicine vol 4 no 3 pp 160ndash163 2003

[16] A Kawamura Y Asakura S Ishikawa et al ldquoExtraction ofpreviously deployed stent by an entrapped cutting balloondue to the blade fracturerdquo Catheterization and CardiovascularInterventions vol 57 no 2 pp 239ndash243 2002

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


(a) (b)

Figure 1 Flextome cutting balloon with extended blades (a) Extracted stent (b)

(ECG) demonstrated normal sinus rhythm with a rightbundle branch block and an old anterior and inferior infarctLaboratory data on admission demonstrated a troponin-I of 005 ngmL (normal reference range lt 002) andBNP gt 5000 pgmL BUN of 20mgdL and creatinine of15mgdL

The patient was admitted to the cardiac step-down unitwith the diagnosis of unstable angina His cardiac biomark-ers trended upward but were in an indeterminate rangeDiagnostic cardiac catheterization was performed coronaryangiography demonstrated focal in-stent restenosis (70ndash80)prior to a bend in the mid ramus intermedius artery Thedecision was made to use CBA for the in-stent stenosisWith a 6 Fr Voda 35 guiding catheter (Boston Scientific) a25 times 10mmcutting balloon (Flextome Boston Scientific) wasintroduced to site of ldquoin-stent stenosisrdquo over 001410158401015840 BMW(balanced middle weight) guide wire and slowly inflatedand deflated Three inflations were performed (7 7 and10 atmospheres) However while withdrawing the cuttingballoon some difficulty was noted Eventually the cuttingballoon was slowly removed via the guiding catheter Thecutting balloonwas carefully examined andwenoticed a stentoverlying the cutting balloon It appeared that the previouslydeployed stent 5 months earlier had been pulled out alongwith cutting balloon (Figure 1)

Repeat coronary angiography demonstrated a dissectionat the previously stented site of the ramus branch Afterseveral attempts a 001410158401015840 whisper wire successfully crossedthe arterial segment Predilations were performed with 25 times20 mini Trek compliant balloon and then 25 times 24mmIon (Boston Scientific) DES stent was deployed at 12 atmo-spheres Poststent deployment angiogram was performedwith and without the wire following the administrationof intracoronary nitroglycerine This showed 0 residualstenosis and TIMI III flow without dissection (Figure 2)Patient was returned to the floor in a stable conditionand has remained asymptomatic on the follow-up clinicvisits

3 Discussion

Cutting balloon angioplasty is one of the common interven-tions for ldquoin-stent restenosisrdquo It has practical benefits overpercutaneous transluminal coronary angioplasty (PTCA)Cutting balloon has an advantage of better anchorage toslippery hyperplastic tissue over traditional PTCA balloonsAlso the expanded blades of a cutting balloon can incisethe tissue up to the stent cage This provides an advantageof deep incision of hyperplastic tissue Restenosis cuttingballoon evaluation trial (RESCUT) clearly demonstratesthese benefits of CBA over PTCA [13] Other techniques (ieexcimer laser atherectomy mechanical atherectomy radia-tion catheter and rotational atherectomy) are also availableto treat in-stent stenosis These techniques are uncommonsecondary to the cost involved in equipment and specializedtraining

Since CBA is a widely used technique it is important tounderstand various complications that may arise during andafter this procedure Various complications related to CBAhave been reported including arterial rupture delayed per-foration stent strut avulsion and fracture of microsurgicalblades [10ndash12] However very few cases have been reportedregarding inadvertent stent extraction as a complicationof CBA In our case we report inadvertent extraction oframus intermedius stent by an entrapped cutting ballooncausing arterial dissection at previously stented site Harband Ling reported on the extraction of a stent deployed atthe coronary ostium that was entrapped by the passage ofa guide wire through protruding stent struts [14] SimilarlyAlmeda and Billhardt reported that a distal RCA stent wasfound attached to microtomes of a cutting balloon uponwithdrawal [15] Another case reported entrapment of stentsecondary to blade fracture leading to stent extraction andacute occlusion of the coronary artery [16] In our case thereason for entrapment is not clear We carefully reviewedthe previous stent angiograms which revealed appropriatesize and deployment Most likely the anatomical bend inthe ramus intermedius artery as well as the entrapment of


(a) (b)

(c) (d)



4 Conclusion




References























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)

(c) (d)



4 Conclusion




References























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Case Report A Rare and Serious Unforeseen Complication...

Documents

Transcript of Case Report A Rare and Serious Unforeseen Complication...