Coronary balloons, semicompliant, compliant, noncompliant balloons, methods of inflation & deflation,

1. Intervention forum
Dr. Rohit Walse

2.  Indeflator
 Compliant and NC balloons – Their inflation & deflation
patterns
 How to deal with common situations faced
 Complications

3.  1 Psi = 0.068 atm
 1:1 Saline : contrast

5.  Loading the monorail over wire
 Evacuation of air to obtain smallest crossing
profile
 Good visibility of the inflated balloon
 Precaution against balloon rupture

11.  The right hand of the operator advances the
balloon while the another operator maintains
gentle traction on the wire.
 The balloon should be advanced by constant
pressure rather than by jerky movements.

14.  More common with short balloons
 Scoring or gripping balloons can minimize
 Slower inflation helps

15.  To secure a more stable position of the guide
 Use a stiffer wire
 To straighten the artery by asking the patient to take a
deep breath
 Constant pressure to advance the balloon while pulling the
wire so that the balloon can cross the lesion
 Using a “buddy” wire, placed adjacent to the primary wire
 A smaller balloon with a lower profile or length may also
succeed in crossing a tight lesion

16.  Guide catheter extensions
 Anchor balloon strategies
 Rotablation / Laser atherectomy

17.  Select a balloon with a length that covers the
lesion well
 Inject the contrast agent while advancing the
balloon

18.  After successful inflation of
the balloon, a small injection
of contrast will verify the
correct fitting of the balloon
with the proximal segment of
the dilated lesion.
 If contrast agent is seen
flowing around the proximal
segment of the inflated
balloon, the balloon is too
small for the artery.

19.  Injecting contrast when the balloon is about to
be inflated.
 If contrast caught in the distal vasculature the
moment the balloon is fully inflated is washed
out promptly, good collaterals are documented.
 If the contrast stays put, the territory is devoid
of collateral blood flow in the event of a later
vessel occlusion

20.  Stable guidewire position and guide position.
 Observe the balloon till it enters the guide.
 Pushing large deflated balloons my suck air
inside
 Always back bleed before any flushing or
contrast injection.

21.  Add another wire and perform force-focused
angioplasty
 Change to a non-compliant balloon and
perform higher-pressure inflation
 Cutting balloon angioplasty for non-calcified
(fibrotic) and calcified lesion
 Rotational atherectomy for calcified lesion

23.  Hugging balloon technique
 Use of a peripheral balloon
 The two balloons are positioned side by side and inflated
simultaneously.
 The combined diameter will be 70% of the sum of each
balloon alone and the cross-section area would be oval
rather than round

24.  For a final assessment, the balloon can be moved
into the proximal part of the dilated vessel or
into the straight part of the guide catheter
shaft, or can even be removed completely.
 Upon contrast injection, the balloon should
never remain in the distal guide catheter
opening where the resultant jet may cause
plaque dissection

25.  Never pull on the balloon
 Keeping the wire fixed, balloon has to be
gently removed after opening the Y-
connector

27. Nanto’s Technique
 With the indwelling wire held immobile, the
balloon catheter is removed slowly until its
proximal hub meets the proximal tip of the wire.
 Attach a 5-ml syringe of contrast to the central
lumen of the balloon catheter.
 Persistently inject the contrast while
simultaneously withdrawing the balloon.
 The wire should not be bent
 The Y-Tuohy catheter should be open.
 The catheter should be positioned on a straight
line, to minimize any friction with the wire

32.  Plaque rupture/dissection
 Stent loss
 Vessel occlusion/thrombus
 Balloon rupture
 Balloon trapping
 Balloon shaft fracture (within or outside the guiding catheter)
 Undeflatable balloon
 Entrapped deflated balloon
 Balloon shearing off
 Coronary & systemic embolilsation

33.  Excessive inflation
 Calcific plaque
 Material fatigue
 Balloon fatigue generally occurs after numerous
inflations and deflations of a re-used balloon
 The sign of material distress or fatigue is that
there is a focal bulging in the balloon during
inflation.

36.  Sudden pressure drop on indeflator
 Blood in the indeflator
 Irregular contrast flow coming from the balloon
and visible on fluoroscopy

37.  Vessel perforation
 Air embolism
 Trapped balloon flaps

38.  Shaft is broken, but still in the guiding
catheter
 Shaft is broken outside of the guiding
catheter
 Panning the fluoroscopy

43.  Deploy a stent and compress it against the
coronary wall
 Potential thrombosis risk with this approach.

44.  Excessive twisting: More than 360° in order to
cross a distal lesion
 Entrapment in the distal portion by a tight lesion
 Using Undiluted contrast

45.  Deflate the balloon with a 50-ml syringe connected directly at the
inflation port
 Dilute the contrast material in the deflator with saline, resulting in
a decrease in fluid viscosity within the balloon.
 Inflate the balloon to rupture it. Prepare for damage control from
dissection or coronary perforation
 Puncture the balloon with the back end of a wire ( Although there
is a risk of coronary perforation, the hole would be quite small and
unlikely to cause any significant complication )
 Surgical removal of the balloon

47.  Push the balloon forward then pull it back
 Twist the balloon in an attempt to rewrap the balloon
before pulling back
 Insert a stiffer wire alongside the entrapped balloon
before pulling the balloon back so that the artery is
straighter
 Advance a second wire distally, then insert an OTW balloon
alongside the entrapped balloon and inflate the new
balloon at low pressure to free the entrapped balloon
 Advance a commercial microsnare and tighten the loop as
near to the balloon as possible, then pull the balloon back

48.  Tortuous, calcified, or angulated coronary lesions

49.  Always use diluted contrast to fill the balloon
 Always wait till the balloon is fully deflated.
Especially for the longer balloons
 Avoid excessive twisting of the balloon catheter