Author + information
- Received September 10, 2013
- Accepted October 9, 2013
- Published online June 1, 2014.
- Naveed A. Adoni, MD,
- Grace W. Huang, DO,
- Umamahesh C. Rangasetty, MD,
- Syed Gilani, MD and
- Ken Fujise, MD∗ ()
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Ranch, Galveston, Texas
- ↵∗Reprint requests and correspondence:
Dr. Ken Fujise, Division of Cardiology, University of Texas Medical Branch, 301 University Blvd, Suite JSA5.106G, Galveston, Texas, 77555.
A critical calcific mid-left anterior descending stenosis of a 54-year-old man with unstable angina was treated with a drug-eluting stent. Except for the rupture of a noncompliant balloon during post-dilation, the procedure was uneventful (Fig. 1A). Shortly before the procedure ended, however, the patient became hypotensive with his typical angina pain. Repeat angiogram now showed a hazy opacity in the left main coronary artery (LMCA) with no flow to the left circumflex (Fig. 1B) The dissection and thrombus formation of the LMCA was suspected. Further hemodynamic deterioration necessitated emergent endotracheal intubation and inotropes. The intravenous infusion of a glycoprotein IIb/IIIa receptor blocker was started. The left anterior descending and 2 obtuse marginal (OM) branches were promptly wired. The small OM1 was not wired. Multiple balloon inflations established the TIMI (Thrombolysis In Myocardial Infarction) flow grade 2 to the arteries (Fig. 1C). An intravascular ultrasound catheter was advanced to the distal LMCA (C-1) and the segment was interrogated with and without ChromaFlo imaging (Volcano Corporation, San Diego, California) (Figs. 1E and 1D, respectively) (size bar = 1 mm) yielding no definitive findings. At that time, an optical coherence tomography (OCT) catheter was advanced and a pull-back image was obtained from the mid-portion of the second OM branch into the LMCA. Strikingly, a small circular material (Fig. 1G,. corresponding to C-3) and a thin membranous material (Figs. 1F and 1G, corresponding to C-1 and C-2, respectively) were now evident, most likely representing a portion of the ruptured balloon trapped in the proximal OM2 and LMCA. Three 0.014-inch wires were also visualized by OCT in the LMCA (Fig. 1F, corresponding to C-1) (size bar = 1 mm). After unsuccessful attempts to retrieve the foreign body, the patient successfully underwent an emergency coronary artery bypass graft surgery.
This is the first case report to demonstrate OCT's ability to image a balloon fragment trapped in the coronary arteries to a resolution that is sufficiently high for clinicians to accurately identify the object. In this case, the accurate characterization and identification of the object allowed the cardiologists not to proceed with the stenting of the LMCA, which would have had a suboptimal outcome due to the uncompressible (Fig. 1H) and highly thrombogenic (Figs. 1F and 1G) materials.
Dr. Rangasetty serves on the Speakers' Bureau for and receives speaking fees from AstraZeneca. Dr. Fujise receives consulting fees from St. Jude Medical, and serves on the Speaker Bureau for and receives speaking fees from Eli Lilly and Boehringer Ingelheim. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 10, 2013.
- Accepted October 9, 2013.
- American College of Cardiology Foundation