Management of a Balloon Shaft Fracture During Subintimal Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention Due to In-stent Restenosis

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of in-stent occlusions can be challenging. If crossing through the stent struts fails, an alternative crossing strategy is to cross beneath the stent struts, followed by implantation of new stents, “crushing” the formerly placed stents. We describe such a case of “sub-stent” CTO crossing using the retrograde approach that was complicated by fracture of the shaft of the balloon used for postdilation (Figures 1A-1L). A similar subintimal crossing and crush technique of an in-stent restenotic lesion in the distal coronary artery has been reported by others, with continued patency documented on coronary angiography performed 9 months later. While the long-term outcomes of subintimal stenting require further study, early results appear promising. 

Balloon shaft fracture can potentially have serious consequences, such as embolization, urgent surgery, or even death. If the balloon fragment is at least partially within the guide catheter, retrieval is usually done by inflating another balloon inside the guide catheter, “trapping” the fractured shaft segment between the balloon and the guide catheter inner wall, followed by withdrawal of the entire system. However, this maneuver was not possible in our case, as the externalized wire was within the antegrade catheter; hence, the antegrade catheter could not be withdrawn with a balloon inflated within its shaft. After measuring the balloon fragment length, it became apparent that it was long enough to be retrieved by withdrawing the antegrade guide catheter (without inflating a balloon inside its shaft), as was successfully done. In summary, subintimal crossing and crushing of an occluded previously deployed stent can allow successful crossing of in-stent CTOs when other strategies fail. Balloon shaft fracture can be challenging to treat in the setting of retrograde CTO-PCI with guidewire externalization; withdrawal of the guide catheter without simultaneous balloon inflation within its shaft may allow successful removal of the balloon shaft fragment if the latter is long enough.