Challenging Case Submission SALMAN ARAIN MD IF AT

Challenging Case Submission: SALMAN ARAIN MD IF AT FIRST YOU DON’T SUCCEED, PRY AND PRY AGAIN! Salman Arain, MD Advocate Medical Group – Midwest Heart Specialists Downers Grove, Illinois

Challenging Case Submission: SALMAN ARAIN MD Case • A 45 year old man with end-stage renal disease underwent replacement of a tunneled dialysis catheter at an out-patient facility. • The procedure was complicated by fracture of the balloon catheter while the balloon was still inflated in the SVC. • The operating physician was unable to remove the balloon, and decided to ‘secure’ it by deploying a selfexpanding PTFE covered stent in the left innominate vein. • The patient was transferred to our facility for possible surgical removal of the balloon. • An angiogram was requested…

Challenging Case Submission: SALMAN ARAIN MD Angiogram via the right internal jugular vein *video loop The initial angiogram shows a partially inflated balloon trapped behind a stent extending from the left innominate vein to the superior vena cava

Challenging Case Submission: SALMAN ARAIN MD Plan A: Retrieve the balloon via the right IJ *video loop A goose neck snare was used to capture the balloon tip. Attempts to retrieve the balloon were unsuccessful, and were aborted after the balloon catheter started to stretch.

Challenging Case Submission: SALMAN ARAIN MD Plan B: Retrieve the balloon via the IVC *video loop Attempts to lasso the balloon from below were initially unsuccessful. A coronary guide was used to optimize the position of the snare, and allow a more superior approach.

Challenging Case Submission: SALMAN ARAIN MD Plan B: Retrieve the balloon via the IVC *video loop Attempts to retrieve the balloon via the IVC was also unsuccessful. The balloon catheter was firmly trapped between the stent and vessel wall.

Challenging Case Submission: SALMAN ARAIN MD Plan C: ‘Pry’ the balloon free *video loop 1. 2. 3. 4. *video loop A coordinated ‘to-and-fro’ movement of both snares was used to free the trapped balloon.

Challenging Case Submission: SALMAN ARAIN MD 1. 3. 2. *video loop The partially inflated balloon was successfully removed from the superior vena cava. Panel 3 shows the partially deflated balloon in the mid- right atrium.

Challenging Case Submission: SALMAN ARAIN MD Removal of the balloon from the body 1. 3. 2. *video loop Removal of the balloon via the venous access site (initially through the 9 French sheath and then without the sheath) was unsuccessful.

Challenging Case Submission: SALMAN ARAIN MD Balloon deflation prior to balloon removal *video loop

Challenging Case Submission: SALMAN ARAIN MD Final result Hemostais was obtained by manual pressure. The patient had an uneventful course after the procedure, and was discharged the next day.

Challenging Case Submission: SALMAN ARAIN MD DISCUSSION