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It was reported that the patient experienced cardiac arrest and was sent for surgery.The target lesion was located in the calcified proximal left anterior descending artery (lad).The vessel was prepped using a 1.25 rota pro burr.A 4.00mm x 30mm emerge balloon catheter was advanced for dilation.However, during inflation at 12-14 atmospheres, the balloon ruptured.During removal of the balloon, the physician felt some resistance.The balloon proximal and distal markers were still visible in the vessel after removing the balloon catheter.Part of the balloon material had been torn and remained in the vessel with the markers.The patient experienced no flow to the lad.Another balloon was used to place the stent were the markers were stuck and the physician was able to restore the blood flow on the vessel.However, the circumflex coronary artery shut down so a routine percutaneous coronary intervention to the vessel was performed to restore blood flow.The patient started to crash so cardiopulmunary resuscitation was performed and a non-bsc device was inserted to the patient.The patient underwent surgery to the groin for the impella/ecmo groin complications.No further patient complications were reported.It was further reported that the target lesion was 90% stenosed, with not much tortuosity and moderate to severe calcification.The patient was doing better post procedure and waiting on a neurological assessment.It was further reported that the patient had diffuse calcified multivessel cad, with definite obstructive severe calcific lad disease.Total lesion length over 60mm total and maximal percent stenosis was 80%.Patient was opted for pci with rotational atherectomy.Given long length of lesion, severe calcification and some tortuousity, and concern for heart block and bradycardia during rotation atherectomy, it was decided to place a temporary pacemaker.R inguinal region had been prepped and draped in sterile fashion.Local anesthesia was administered via 1% subcutaneous lidocaine to r inguinal region.Using a micropuncture needle/system and a modified seldinger technique, a 5f sheath was placed in the right femoral vein.A temporary pacemaker wire was then advanced with balloon tip inflated under fluroscopy into the right ventricle and positioned appropriately.Pacemaker capture and function were confirmed.A non-bsc guide catheter was used to engage to ostium of the lmn.Anticoagulation was administered with heparin per weight based algorithm and act monitored throughout the case.A non-bsc guidewire was advanced into the distal lad and exchanged over microcatheter for a floppy rota guidewire.A 1.25 mm burr was selected.The device was prepped in standard fashion outside the body and tested.It was advanced into the proximal lad.And four runs were performed in standard fashion successfully and felt to be sufficient for plaque modification.No significant hemodynamic or arrhythmic issues were observed during the runs.Repeat angiography revealed timi iii flow and no compromise of diagonal branches.A non-bsc wire was advanced into the distal lad to be utilized as the primary guidewire for pci performance.A 3.0 x 30 mm angioplasty balloon catheter was then advanced into the lad.Serial inflations were performed at 16 atmospheres.On the most proximal inflation, there was a "waist"/incomplete expansion, and balloon rupture.A 4.0 x 15 mm ptca balloon was advanced into the lad and 3 total inflations were performed in the proximal half of the lesion.However, there was a watermelon seeding of the ptca balloon during inflations and were unsure whether the area of interest in the proximal half of the balloon was adequately expanded.As such, a 4.0 x 30 mm ptca balloon catheter was advanced into the lad and serial inflations were undertaken from the distal to proximal aspects of the lesion in the lad.The balloon fully expanded at the proximal aspect of the lesion at approximately 14 atmospheres but burst.Negative suction was applied immediately on the indeflator system.Physician then encountered difficulty in withdrawal of the ptca balloon catheter despite multiple maneuvers including additional negative pressure/suction of indeflator device, attempts to advance balloon then pullback, gentle pullback with the guide positioned in the aorta/ostial left main, and advancing the guidecatheter forward over the balloon catheter with gradual gentle pullback force, and attempting to draw back with guide catheters and wire together.Despite these maneuvers, the balloon catheter fractured within the vessel ad balloon remnant was left within the left coronary.Repeat angiography revealed complete obstruction of the lad with no flow into the mid-distal lad.The patient was experiencing chest pain but hemodynamically stable at this time.Assistance from anesthesia was requested immediately.Immediately proceeded with femoral artery access utilizing a modified seldinger technique and micropuncture system.An 8f sheath was placed in the right femoral artery (rfa) and a non-bsc guide catheter was utilized to engage to left main ostium.Physician was able to traverse around the ruptured balloon fragment with a non-bsc wire.The wire was exchanged with another 0.014 non-bsc wire over a microcatheter.Ptca at the site of obstruction was performed with a 2.0 x 20mm pcta balloon at 20 atmospheres with restoration of timi iii flow.Anesthesia team was now present and assisting including with sedation and airway management.Chest pain was subsided also at this time and the patient was comfortable and hemodynamically stable still.From the time of balloon fracture to restoration of timi iii flow, approximately 10-11 minutes had transpired.Additional predilatation was then performed with a 3.0 x 15mm balloon as well as a 3.5 x 20 balloon at 20 atmospheres, with good balloon expansion and no "waist".Physician carefully but repeatedly tried to see if the fractured segment of the balloon could be trapped back into the guide with the balloon next to it.However, with positioning of the 3.0 x 15 mm and the 3.5 x 20 mm balloons distalto the lesion, advancing the guide and with gentle pullback, it appear that gragmented 4.0 x 30 mm balloon was fairly entrapped on the vessel wall, with the assumption being that it was trapped through/agains a "shard" of calcified plaque.Further options at this point included emergent eluting stent.Ivus performed and revealed that while the ptca balloon "dots" extended from the distal left main/ostium of the lad to the first septal branch, physician could ptca balloon segment to extend to the ostium of the left main coronary artery.The stenting through the lad had been revascularized, without repeat inflations at the site of the entrapped balloon, the lad would re-occlude within 1 minute each time after an inflation, and the patient would become very symptomatic again, and this represented an unstable anatomy that required mechanical correction/stabilization immediately.After discussion, it was felt that pci with the drug-eluting stent (des) would be the most appropriate option with the exclusion of entrapped balloon from the vessel lumens with des.Physician wired the large second diagonal brach with a non-bsc wire.The plan was to stent the lad from mid-vessel all the way back to the left main ostium, with intention of stenting balloon fragment into vessel wall and excluding it from the vessel lumen.A 3.5mm x 38mm synergy des was advanced to the mid lad and positioned in the distal aspect of the diseased segment.After correct positioning was confirmed by angiography, it was deployed at 16 atmospheres.The stent delivery system was utilized to perform additional predilatation of the proximal-mid lad as there was a repeat compromise of flow from the fragmented balloon.Repeat angiography revealed complete closure/jaily of second diagonal branch from the 3.5 x 38 mm synergy des even though the vessel was wired beforehand with a non-bsc wire and even though there was no significant stenosis/compromise of the ostium post ptca and prior to des implantation.Physician proceeded to attempt to re-wire the second diagonal brach, but multiple attempts with multiple non-bsc wires were not successful.Physician was unable to cross the vessel architectural but felt the guidewire was not in the true lumen and not cross into the true lumen despite multiple attempts at approximately 10 minutes and even with removal of the initial guide wire in the second diagonal.Physician decided to proceed with pcix of prox lad and left main at this point to achieve mechanical stabilization/control of these vessels.A 4.0 x 38 m synergy des was advanced into the poximal lad and positioned such that there was 1-2mm overlap with the previously deployed at 16 atmospheres with good expansion noted and the zone of overlap between the 2 stents was post dilated at 12 atmospheres.A new non-bsc wire was advanced into the left circumflex artery prior to left main stenting.Additional predilatation of the left main was performed with a 4.0 x 15 mm ptca balloon at 16 atmospheres with good expansion.As there was no compromise of the ostium of the left circumflex artery after pre-dilationof the left main coronary artery, we decided to proceed with an initial provisional/single stent strategy for stenting of the left main coronary artery.A 4.5 x 20 mm synergy was advanced into the lmn and positioned such that there was minimal overlap with the 4.0 x 38 mm synergy stent and tha the proximal stent protruded beyond the ostium of the lad by 1-2mm.The stent was then deployed at 16 atmospheres and the ostium was post-dilated/flared at 20 atmospheres.In summary, from distal to proximal the physician implanted 3.5x38mm, 4.0x38mm and 4.520mm synergy stents with good stent expansion seen.The entire stented length of the 4.0 x 20 mm synergy stent in the left main, the entire length of the 4.0 x 38mm synergy stent in the proximal lad, the zone of overlap between the left main/lad stent as well as the lad stents were post dilated with the 4.5 x 20 mm balloon at 16 atmospheres with multiple serial overlapping inflations with good balloon expansion noted.Repeat angiography revealed satisfactory result in the stented segments and no significant compromise of the lcx ostium with timi iii flow noted in both the lad and lcx coronary arteries.Attempts to re-wire through the stent struts into the true lumen.A non-bsw wirs utilized without success in getting into the true lumen, and considered dissection/re-entry technique if further wire attempts were not successful.However, at this time, the patient was noted to be hypotensive and with poor o2 sats despite airway control/vent by anesthesia.Repeat angiography now revealed 99%/subtotal occlusion of the lcx ostium that was new.There was concern for thrombus formation on the entrapped balloon fragment.A new non-bsc guidewire was repositioned into the distal lcx coronary artery.Additional predilatation of the left circumflex ostium was performed with a 3.0 x 12 mm ptca balloon at 14 atmospheres with good balloon expansion.Given concern that the entrapped balloon segments could be interfering with the lcx ostium and flow, physician proceeded with stenting of the lcx coronary artery and a tap stenting technique was utilized.A 3.0 x 12 mm synergy ii drug-eluting stent was positioned at the ostium of the lad/distal lmn.After correct positioning was confirmed angiography, the 3.0 x 12 mm synergy des was deployed at 16 atmospheres.The stent delivery system was then pulled back 2-3 mm, aligned with the 4.0 x 12 mm ptca balloon catheter in the lad and simultaneous kissing balloon inflations were performed times two at 14 atmospheres.Repeat angiography revealed 0% residual stenosis and timi grade iii flow.However, patient remained in shock, hypotensive and hypoxic.We decided to proceed with percutaneous lvad placement with impella cp.Using a micropuncture system and a modified seldinger technique, an impella sheath was placed into the rfa and a 6f pigtail catheter was advanced into the lv and exchanged over guidewire for the impella catheter.Patient had vf during impella placement which was successfully defibrillated at 200 joules.Hemodynamic support was initiated with impella but patient remained in shock and very hypoxic despite endotracheal intubation with correct positioned confirmed by anesthesia and radiographically.Physician felt that ecmo would represent the best option for oxygenation and hemodynamic support.Cardiac surgery was consulted emergently.Also repeat angiography revealed occlusion of the mid lcx (which previously had a 50-60% stenosis) now despite adequate act earlier, possibly secondary to thrombus embolism.The mid left circumflex was predilated with a 2.0 x 12 mm balloon at 12 atmospheres followed by stenting with a 3.0 x 12 mm synergy ii drug-eluting stent at 16 atmospheres with 0% residual stenosis and timi iii flow.Patient remained profoundly hypoxic and in shock despite all efforts including inotropic support, vent support with 100% fio2 by anesthesia, and hemodynamic support with impella cp percutaneious lvad.Cause of hemodynamic instability was felt to be likely/at least in part secondary to cumulative ischemia in multiple territories with ischemic mr.Ecmo team had arrived and were in process initiating ecmo insertion.Po2 values were severely reduced on abg and in the 20-30 range despite fio2 100, intubation, mechanical ventilation and peep.They were ultimately corrected post ecmo on the circuit.Right heart catheterization was done to better define hemodynamics and aid in the management of volume/hemodynamic management.The temporary pm catheter was removed and the 5f rfv sheath was exchanged for an 8f sheath.A 7f swan ganz catheter was advanced with balloon tip inflated over pressure and fluoroscopic guidance into the ra, then rv, then pa and then pcwp position.Hemodynamics were recorded.Patient had second episode of vf which was promptly defibrillated at 200 j.No cpr was needed/performed.Also, since the beginning of when hemodynamic compromise was noted, cardiac tamponade was ruled out multiple times with bedside ultrasound, bedside tte and tee.At the time of initial episode of hypotension post left main stenting lvef was approximately 40% or so and there was no significant pericardial effusion.At the time of ecmo placement lvef was approximately 10% but no evidence of cardiac tamponade.Final angiography had revealed no stenosis in the stented segments of the lad, lcx and the left main coronary arteries with timi iii flow.Second diagonal branch remained occluded.The impella cp sheath was secured/sutured.
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