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Effectiveness of the hugging balloon technique in coronary angioplasty for a heavy, encircling, calcified coronary lesion.
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MedLine Citation:
PMID:  19997547     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
We report our experience in coronary angioplasty and intravascular ultrasonography (IVUS) on a heavy, encircling, calcified lesion that was not dilated with the use of a cutting balloon and a non-compliant balloon. The angioplasty was successfully performed with a simple and inexpensive hugging balloon technique.
Authors:
Min Soo Ahn; Junghan Yoon; Jun Won Lee; Kyoung Hoon Lee; Jang Young Kim; Byung Su Yoo; Seung Hwan Lee; Kyung Hoon Choe
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Publication Detail:
Type:  Journal Article     Date:  2009-11-30
Journal Detail:
Title:  Korean circulation journal     Volume:  39     ISSN:  1738-5555     ISO Abbreviation:  Korean Circ J     Publication Date:  2009 Nov 
Date Detail:
Created Date:  2009-12-09     Completed Date:  2011-07-14     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101247141     Medline TA:  Korean Circ J     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  499-501     Citation Subset:  -    
Affiliation:
Department of Cardiology, Pusan National University School of Medicine, Busan, Korea.
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Full Text
Journal Information
Journal ID (nlm-ta): Korean Circ J
Journal ID (publisher-id): KCJ
ISSN: 1738-5520
ISSN: 1738-5555
Publisher: The Korean Society of Cardiology
Article Information
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Copyright ? 2009 The Korean Society of Cardiology
open-access:
Received Day: 16 Month: 5 Year: 2009
Revision Received Day: 23 Month: 7 Year: 2009
Accepted Day: 05 Month: 8 Year: 2009
Print publication date: Month: 11 Year: 2009
Electronic publication date: Day: 30 Month: 11 Year: 2009
Volume: 39 Issue: 11
First Page: 499 Last Page: 501
ID: 2790133
PubMed Id: 19997547
DOI: 10.4070/kcj.2009.39.11.499

Effectiveness of the Hugging Balloon Technique in Coronary Angioplasty for a Heavy, Encircling, Calcified Coronary Lesion
Min Soo Ahn, MD1
Junghan Yoon, MD2
Jun Won Lee, MD2
Kyoung Hoon Lee, MD2
Jang Young Kim, MD2
Byung Su Yoo, MD2
Seung Hwan Lee, MD2
Kyung Hoon Choe, MD2
1Department of Cardiology, Pusan National University School of Medicine, Busan, Korea.
2Department of Cardiology, Wonju College of Medicine, Yonsei University, Wonju, Korea.
Correspondence: Correspondence: Junghan Yoon, MD, Department of Cardiology, Wonju College of Medicine, Yonsei University, 162 Ilsan-dong, Wonju 220-701, Korea. Tel: 82-33-741-0917, Fax: 82-33-741-1219, jyoon@yonsei.ac.kr

Introduction

Significant calcification of coronary artery lesions has been identified as a strong predictor for decreased success and increased complication rates with balloon angioplasty. Calcium imposes a rigid obstacle to optimal and symmetric stent expansion and results in smaller acute gain, and stent under-expansion is associated with an increased risk of acute stent thrombosis and re-stenosis, even with drug-eluting stents (DES). Percutaneous coronary intervention (PCI) for calcified lesions remains a therapeutic challenge. We report a useful technique, the "hugging balloon technique," using two small balloons to treat encircling, heavily-calcified lesions.


Case
Case 1

A 76-year-old male patient presented to us with an anterior ST elevation myocardial infarction (STEMI) that developed 3 hours previously. Primary PCI was performed and coronary angiography showed a heavily calcified total occlusion at the proximal left anterior descending (LAD) artery. The lesion was pre-dilated with a 2.5?15 mm balloon (Voyager, Guidant, Indianapolis, IN, USA), but the balloon ruptured at 12 atm and a type C dissection was noted. Two paclitaxeleluting stents (3.0?28 mm, and 3.0?20 mm, Taxus?; Boston Scientific, Boston, MA, USA) were deployed at the midLAD. A follow-up angiogram showed residual stenosis and haziness at the previous calcified total occlusion site (Fig. 1A). After dilatation of the adjuvant balloon 10 times with a 3.0?10 mm balloon (20 atm, Vigor; OCCAM, Eindhoven, Netherlands) and a 3.0?12 mm balloon (Quantum Maverick; Boston Scientific), severe stenosis remained. Intravascular ultrasound (IVUS) revealed an encircling heavy calcification at the previous total occlusion site (Fig. 1C). The hugging balloon technique was performed with two 2.0?15 mm balloons (Splinter; Medtronic, Minneapolis, MN, USA). Two balloons were located at mid-LAD in parallel, and stepwise inflations were performed simultaneously at 12, 18, and 20 atm (Fig. 1B). After the 20 atm ballooning, the lesion site was expanded. Repeated balloon dilatations were performed several times with a 3.0?12 mm balloon (Quantum Maverick). A follow-up angiogram showed resolution of the stenosis and IVUS showed an ellipsoidal rupture of the encircling calcification (Fig. 1D).

Case 2

A 68-year-old male was admitted for a STEMI that developed 4 hours previously. Primary angioplasty was planned and the angiogram revealed total occlusion with thrombus and heavy calcification at the mid-LAD artery. After manual aspiration (Thrombuster; Kaneka, Osaka, Japan), an angiogram showed that the heavily-calcified stenosis remained at the mid-LAD artery (Fig. 2A). IVUS revealed a heavy, encircling calcification (Fig. 2C). The lesion was pre-dilated with a 3.0?15 mm balloon (Maverick balloon at 9 atm) and a 3.0?10 mm cutting balloon, but the balloons were not fully dilated at the lesion site. We attempted the hugging balloon technique. Two balloons were located in the mid-LAD artery, side-by-side (2.5?15 mm, and 1.5?15 mm Maverick) and were stepwise inflated simultaneously at 10 and 12 atm. These two balloons were fully expanded and there was no indentation (Fig. 2B). Even though the balloons were fully expanded, the lesion recoiled. However, IVUS revealed breakage of the encircling calcification (Fig. 2D). Then, additional balloon dilation was performed with a cutting balloon. Three sirolimus-eluting stents (2.5?33 mm, 2.75?23 mm, and 3.0?23 mm, Cypher?; Cordis, Johnson & Johnson, FL, USA) were then successfully implanted in the mid-LAD artery. Final angiography showed good dilatation and patency of the LAD artery.


Discussion

These cases highlight the potential efficacy of a double balloon for managing severely calcified lesions. A finding of extensive calcification may lead to the use of plaque modification strategies, such as atherectomy devices or cutting balloon inflation. Rotational atherectomy (RA) has been shown to be efficient for selective calcium ablation.1), 2) High-speed RA preferentially cuts hard plaque, increasing plaque compliance, and thereby rendering the lesion more amenable to balloon dilatation.1) However, the potential exists for microcirculatory impairment due to embolization of plaque debris, platelet aggregation, or vasospasm.3) The cutting balloon creates small, sharp, and regular incisions in the plaque and relieves the hoop stress of the vessel, thereby lessening the continuity and rigidity imposed by calcium. The efficacy of the cutting balloon for a calcified lesion has been demonstrated in previous reports,4) but the cutting balloon poses the risk of coronary rupture, microblade fracture and subsequent coronary mural hematoma because of the blades around the surface of the balloon.5)

A small portion of lesions are refractory to coronary angioplasty, even when very high pressures are used. In double balloon mitral valvulotomy, the tension applied to the plane of the mitral commissures is twice the tension applied vertically, resulting in a more elliptical mitral valve shape, more effective splitting of the fused commissures, and less risk of rupturing or tearing of the leaflets.6) Based on La Place's law for surface tension, higher pressures can be attained with smaller balloons as the burst pressure is higher in smaller balloons compared to larger balloons, as follows: surface tension=pressure?radius. This technique successfully dilates the lesion as the geometry of two balloons inflated side-by-side is different from one balloon. Two balloons consist of two outer semi-circles and a central trapezoidal square area. This altered geometric configuration may be important in successfully dilating a lesion refractory to standard dilating techniques. The determination of adequate diameters is based on the formula, "R2=D12+D22", by adjusting the balloon diameters (D1 and D2) to pre-dict the theoretical mean hugging balloon diameter (R).7)

The preferred choices for management of heavy, calcified coronary lesions are RA or a cutting balloon. However, the judicious use of hugging balloons can be considered in the management of heavy calcified lesions to facilitate adequate dilatation of the lesions when other non-compliant balloons have failed.


References
1. Mintz GS,Potkin BN,Keren G,et al. Intravascular ultrasound evaluation of the effect of rotational atherectomy in obstructive atherosclerotic coronary artery diseaseCirculationYear: 199286138313931423950
2. Kim MH. Initial experience of rotational atherectomy in coronary artery diseaseKorean Circ JYear: 199929567574
3. Abbo KM,Dooris M,Glazier S,et al. Features and outcome of no-reflow after percutaneous coronary interventionAm J CardiolYear: 1995757787827717278
4. Karvouni E,Stankovic G,Albiero R,et al. Cutting balloon angioplasty for treatment of calcified coronary lesionsCatheter Cardiovasc IntervYear: 20015447348111747183
5. Quan VH,Stone JR,Couper GS,Rogers C. Coronary artery perforation by cutting balloon resulting in dissecting subepicardial hematoma and avulsion of the vasculatureCatheter Cardiovasc IntervYear: 20056416316815678461
6. Bassand JP,Schiele F,Bernard Y,et al. The double-balloon and Inoue techniques in percutaneous mitral valvuloplasty: comparative results in a series of 232 casesJ Am Coll CardiolYear: 1991189829891894873
7. Morino Y,Yamamoto H,Mitsudo K,et al. Functional formula to determine adequate balloon diameter of simultaneous kissing balloon technique for treatment of bifurcated coronary lesions: clinical validation by volumetric intravascular ultrasound analysisCirc JYear: 20087288689218503211

Article Categories:
  • Case Report

Keywords: Coronary artery stenosis, Angioplasty, balloon, Intravascular sonography.

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