Get Out of Jail

Balloon entrapment is a potentially fatal complication of percutaneous coronary intervention. This report describes the use of subintimal plaque modification for the management of entrapped balloons. This technique, commonly done during chronic total occlusion angioplasty, was used successfully to retrieve the balloon. (Level of Difficulty: Advanced.)


PAST MEDICAL HISTORY
The patient had no significant cardiac or extracardiac medical history.

INVESTIGATIONS
We attempted to remove the balloon by forceful traction, but the distal marker started lengthening as we pulled further. We were able to partially pull the balloon into the guiding catheter, but neither the balloon nor the wire could be removed further. A

LEARNING OBJECTIVES
To perform a meticulous management algorithm for balloon entrapment during percutaneous coronary intervention to improve patient outcomes. To describe the subintimal calcium modification technique as a bailout strategy in the case of balloon entrapment. To promote the importance of lesion preparation with adequate calcium modification techniques to avoid these complications.
balloon fragment was still present in the mid RCA on angiography. The patient developed chest pain at this point and the antegrade flow was TIMI flow grade 1.

MANAGEMENT
We cut the balloon shaft and advanced a 5.5-F Guideliner (Teleflex), with deep intubation of our guiding catheter, but the guiding extension was unable to advance past the balloon fragment in the mid RCA. Further, directed pulling through the guide extension catheter did not allow the retrieval of the entrapped balloon. Subsequently, we obtained a right femoral artery access to advance another 6-F Judkins Right guiding catheter to perform the Ping-Pong technique 1 ("use of 2 guide catheters into the same coronary artery"). We were unable to advance a guidewire into the true lumen, as the balloon fragment was obstructing the stenosed segment mid RCA ( Figure 1C, Video 3). At this point, the usual described maneuvers for retraction of entrapped gear had been attempted with no success. We decided that advanced chronic total occlusion (CTO) techniques were necessary. The initial plan was to obtain subintimal access proximal to the entrapped balloon and try a distal reentry and external plaque crush to dislodge the balloon.
A guidewire was used to access the subintimal space proximal to the entrapped gear, followed by a microcatheter Turnpike LP (Teleflex) and was advanced beyond the entrapped balloon. An attempt to reenter the true lumen was performed at this stage with a Gaia 3 Next wire (Asahi Intecc), but failed. A Gladius Mongo 14 (Asahi Intecc) was advanced into the subintimal space at the mid vessel, and a subintimal tracking and reentry was attempted but was also unsuccessful ( Figure 1D, Video 4).
We thought of using a String-ray balloon (Boston Scientific), yet we wanted to avoid the use contrast,

DISCUSSION
In this report, we describe the use of a subintimal plaque modification technique by side-ballooning the subintimal space, which is the first time this bailout strategy was undertaken to manage this rare complication. The incidence of entrapped material during PCI is reported at a rate between 0.4% and 1.0%, and the incidence of balloon entrapment is even lower.
However, despite this rare occurrence, entrapment of a balloon is a potentially fatal complication and must be managed urgently. We reviewed the literature by searching PubMed for occurrences of balloon entrapment using the keywords "balloon entrapment," "balloon rupture," and "undeflatable balloon" and found 21 cases highlighting this complication (Supplemental Table 1). Use of subintimal calcium modification technique for retrieval of an entrapped balloon has never been described.
Most of these cases occurred in the left anterior descending artery (n ¼ 9 of 21; 42.8%) and in the RCA

FOLLOW-UP
The patient was discharged 3 days later, after an uneventful postprocedural course. Peak troponin T Hs level was reached the next day (659 ng/L).

CONCLUSIONS
The subintimal plaque modification technique is a bailout strategy for balloon entrapment and should be kept in mind in these critical situations.