Introduction
Percutaneous coronary intervention is a widely used and generally safe procedure for the treatment of CAD. Balloon catheter detachment within a coronary artery is an uncommon but serious event that requires immediate recognition and management. We present a complex case of a detached balloon in the RCA during primary PCI for STEMI, highlighting the diagnostic considerations and management strategies.
Case:
A 77-year-old man was transferred for ongoing inferior STEMI. At the referring hospital, PCI of the RCA with implantation of three DES was performed. During retrieval, the delivery balloon of the final stent became trapped. Subsequent extraction attempts resulted in shaft rupture, leaving the collapsed balloon within the mid-RCA. A bedside Heart Team discussion led to the decision to pursue an interventional rather than surgical retrieval strategy. Rewiring past the detached balloon was achieved using a microcatheter and a standard workhorse wire. Multiple retrieval attempts using snaring techniques and a guide extension catheter failed. The balloon was partially mobilized via serial balloon dilatation alongside the detached device. However, extraction using a trapping balloon remained unsuccessful. A bailout strategy with stent implantation over the retained balloon was performed, followed by high-pressure post-dilatation. IVUS revealed a distal RCA dissection, which was successfully sealed with an additional DES. At 5-month follow-up, angiography and OCT showed a satisfactory intermediate result in the stented segments of the RCA.
Discussion:
Balloon entrapment and catheter shaft rupture during PCI are rare but serious complications that challenge interventional management. Entrapment commonly occurs due to complex lesion morphology, heavy calcification, stent strut interaction, or aggressive device manipulation. Retained balloons risk vessel occlusion, thrombus formation, dissection, and distal embolization. Management of retained intracoronary devices requires a careful, stepwise approach. Initial attempts generally focus on percutaneous retrieval using snaring techniques and guide extension catheters. However, success rates vary and may be limited by the location, size, and entrapment mechanism of the device. In our patient, despite successful wiring distal to the lesion and multiple retrieval maneuvers, complete removal of the detached balloon failed. This necessitated an alternative bailout strategy: stent implantation over the entrapped device. This approach effectively secured the retained balloon against the vessel wall, restored luminal patency, and prevented further adverse events. The patient remained asymptomatic at 5 months, underscoring the feasibility and safety of this strategy. This case underscores the importance of early recognition, systematic retrieval protocol, the utility of intravascular imaging and the value of a Heart Team approach in managing complex PCI complications. Stenting over an entrapped balloon represents a viable bailout option when percutaneous retrieval fails, with favorable mid-term outcomes.
Conclusion:
Balloon catheter detachment during PCI remains a rare but serious complication requiring prompt recognition and tailored interventional strategies. In selected cases, stenting over the retained device may serve as a safe and effective bailout option.
