Case report
We report a case where a soft balloon was inappropriately selected for right ventricle to pulmonary artery conduit angioplasty and was retained within the calcified conduit after rupturing, requiring innovative manoeuvres to remove it. A 13-year-old girl with pulmonary atresia and ventricular septal defect underwent Rastelli repair at the age of 9 years using a handmade bovine pericardium conduit (size 20 mm). She developed progressive stenosis of the right ventricle to pulmonary artery conduit (echocardiographic peak gradient of 75 mmHg across the stenosis), and balloon dilatation was planned to delay conduit replacement.
Using a percutaneous technique, both venous and arterial access were achieved. The haemodynamic assessment confirmed a severe stenosis with an right ventricle pressure of 95 mmHg against an aortic pressure of 110/75 mmHg. The pulmonary artery pressure was 30/16 mmHg with an estimated gradient across the stenosed conduit being 65 mmHg under general anaesthesia. Right ventricle angiogram showed a calcified right ventricle to pulmonary artery conduit with severe stenosis and preserved systolic right ventricle function (Figure 1). A 20 mm x 4 cm OXYPKA VACS II valvuloplasty balloon (OSYPKA AG, Germany) was taken over the 0.035 exchange wire and placed across the conduit in the left pulmonary artery (LPA). On inflation, the waist was partially relieved, but the balloon ruptured (Figures 2, 3). In an attempt to remove the balloon, it became entrapped within the heavily calcified tissue. Various manoeuvres, such asrotational movements, gentle jerk, and inflation with saline, were attempted to release the balloon but were unsuccessful.
RV angiogram (full lateral) showed calcified RV–PA conduit with severe stenosis, RVH with good functions.
RV–PA conduit angiogram (Full lateral) showed partial inflation, partial relief of waist and circumferential rupture of 20 mm x 4 cm OSYPKA VACS II valvuloplasty balloon and release of contrast media in RV to PA conduit.
RV–PA conduit angiogram (full lateral) showed circumferential rupture of 20 mm x 4 cm OSYPKA VACS II valvuloplasty balloon and release of contrast media into branch PAs.
Another venous access was established, and a super-stiff wire was placed in the right pulmonary artery (RPA) (Figure 4). A 20 mm x 5 cm NuMED BIB Balloon Catheter (NuMED, USA), the only high-pressure balloon available from Cheetham Platinum (CP) stent kit, was placed across the conduit. The inner balloon was inflated first, followed by the outer balloon at a rated burst pressure of 6 atmospheres. The waist disappeared completely (Figure 5), and a repeat inflation was performed to achieve a sustained result. After successful ballooning with the 2nd balloon, it was possible to pull the first balloon from conduit down to the femoral sheath (Figure 6).
RV angiogram (AP projection) showed another super-stiff wire placed in RPA through 2nd venous access (first wire was in LPA).
RV–PA conduit angiogram (full lateral) showed inflated 20 mm x 5 cm NuMED BIB stent placement balloon catheter placed across the narrowed segment with relieve of waist.
Ruptured OSYPKA VACS II valvuloplasty balloon being removed from right femoral vein.
As we attempted to remove the balloon from the femoral sheath, it became apparent that the balloon had ruptured circumferentially. The distal part had flared in the reverse direction and so could not be retracted into the femoral sheath. During the manipulation to bring it into the sheath, the distal portion of the balloon completely separated from the catheter, and its position was stabilised near the femoral vein by the guidewire. A femoral vein surgical cut down was performed, and after acheiving proximal and distal control of the femoral vein, the distal end of the balloon was retrieved (Figure 7). The femoral vein was then repaired, and haemostasis was secured.
Circumferentially ruptured OSYPKA VACS II valvuloplasty balloon with complete removal of the ruptured fragments.
Discussion
Percutaneous techniques, including balloon dilation and endovascular stenting, have been used to relieve obstructions and prolong the functional lifespan of right ventricle–to–pulmonary artery homografts and bioprosthetic conduits. Reference Peng, McElhinney and Nugent1–Reference Zeevi, Keane, Perry and Lock5 Percutaneous balloon angioplasty of stenosed conduits has shown marginal efficacy in reducing pressure gradients and avoiding surgical or percutaneous pulmonary valve replacement. Reference Zeevi, Keane, Perry and Lock5–Reference Lloyd, Marvin, Mahoney and Lauer7 In low- and middle-income countries, the financial ramifications are notably substantial; hence, handmade conduits are often preferred, and attempts are made to dilate the stenosed conduits with balloon angioplasty to postpone the need for additional surgery by a few years. Reference Shah, Khan and Asaf8–Reference Hainstock, Marshall, Lock and McElhinney10
This case highlights an important complication of balloon angioplasty where a balloon got stuck within the conduit and could not be released by standard manoeuvres. The most likely reasons were incomplete relief due to the use of a soft balloon, rupture due to heavy calcification, and dragging the balloon out of the conduit, which probably led to additional tearing and ultimately a circumferential tear. The Osypka VACS II balloon is a soft, compliant, low-pressure balloon designed for balloon valvuloplasty of stenotic native pulmonary or aortic valves, with a nominal pressure of 1.5 ATM and a burst pressure of 2 ATM. The selection of this balloon for a calcified xenograft conduit was due to limited availability of options. A semi-compliant balloon that withstands pressures of 5–6 ATM or a noncompliant balloon that can be inflated to 10–12 ATM would be preferred for a calcified conduit. These balloons were not available, and the only semi compliant balloon available was the Numed BiB balloon, which was not used initially because it comes with the Numed CP stent as part of the complete kit.
Another factor could be the use of a normal stiffness wire. The use of an inappropriate wire could have contributed to the difficulty in retrieving the ruptured balloon due to insufficient wire support. Inability to retrieve the balloon would have necessitated emergency surgery. Using a high-pressure balloon, a super stiff wire, a different landing zone for the wire and achieving complete relief of the obstruction helped free the balloon from the calcified stenosed conduit.
The circumferential tear led to another challenge as it was not possible to bring the distal balloon into the femoral sheath. Further manipulation and attempts to pull the distal balloon back completely disconnected it from the proximal part. We decided to proceed with a surgical cut down of the femoral vein to remove the distal balloon. Upon visualisation, it was apparent that the balloon remained on the wire. Another option would have been a contralateral venous access, placing a larger French sheath in the other groin and using a snare to retrieve the wire and the broken distal part into the left groin sheath, which would have altered the angle of the distal broken segment, making it possible to remove it through the sheath. New devices that help compress large objects like tumours, balloons, Atrial Septal Defect (ASD) devices, pulmonary valve devices, and other intracardiac foreign bodies now exist. ŌNŌ retrieval system (ŌNŌCOR Vascular) has been used successfully to augment the snaring of the Sapien balloon fragments that ruptured during conduit ballooning, as reported in a recent case series. Reference Basman, Kodra and Mustafa11 However, this device was not available to us.
Acknowledgements
Dr Noor Masood Sadiq for grammatical corrections, stylistic changes, and overall corrections of English language.
Author contribution
Omeir Ali Aziz: Original case co-operator, data curation; formal analysis; roles/writing – original draft.
Asim Khan: Original surgical help, formal analysis; supervision; validation; writing – review and editing.
Masood Sadiq: Original case operator, conceptualisation; supervision; validation; writing – review and editing.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
None.
Ethical standard
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008, and has been approved by the institutional review board of The Children’s Hospital Lahore.
