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E1010. Wait, Where Did it Go? Angioplasty Balloon-Catheter Embolism to the Left Pulmonary Artery
Authors
  1. Saad Farooq; KPC Health
  2. Drew McKinney; St. George's University
  3. Krishna Das; Hudson Valley Radiologists
  4. Rahul Nayyar; Victor Valley Global Medical Center
Background
Catheter related complications are known and well-documented in interventional radiology. The failure of an angioplasty balloon is a rare complication and is reported in approximately 0.2% of cases [1]. Balloon failure and migration can occur for various reasons including procedure location, intravascular calcification, faulty machinery, etc. Management is dictated primarily by the fragment size and where it becomes embedded [2]. This report details the incidence of a portion of an angioplasty balloon dislodging, embolizing, and the attempt to retrieve it from the left main pulmonary artery.

Educational Goals / Teaching Points
In this exhibit we describe a case of angioplasty balloon fracture and fragment embolization. The goal of this exhibit is to discuss the associated imaging findings and the steps that were undertaken to attempt to retrieve the balloon fragment from the pulmonary artery. Knowledge of this particular type of device complication as well as post-embolization management will serve as a guide when similar obstacles arise mid-procedure.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
A hemodialysis dependent patient presents with right subclavian and brachiocephalic vein stenosis. We show successful balloon-angioplasty via sequential fluoroscopic images of the right subclavian/brachiocephalic vein. During the second intra-stent angioplasty, a portion of the 16 x 4cm balloon was fractured and a fragment migrated centrally. The balloon fragment’s location was confirmed in the left pulmonary artery on non-contrast computed tomography (CT) of the chest. Sequential fluoroscopic images demonstrate the right femoral vein approach is utilized to gain access to the inferior vena cava (IVC) and then the pulmonary tree. A retrieval attempt was made using a 7 French long sheath and a snare device (goose-neck and ensnare) from the pulmonary artery. Multiple attempts to dislodge and retrieve the fragment in this manner are ultimately unsuccessful. As intravascular foreign bodies are a nidus for thrombus formation, the patient was started on anticoagulation and cardiothoracic surgery consultation was recommended.

Conclusion
Angioplasty balloon fracture and migration is a known but relatively rare complication in interventional radiology. There is potential for severe morbidity and mortality if a broken fragment embolizes to the pulmonary tree. In this report we detail the procedural steps as well as the fluoroscopy and CT imaging that were utilized to guide the procedure as well as the retrieval attempts. The purpose of reporting this case is to not only bring awareness to this rare complication but to also discuss medical and/or surgical management.