Ruptured and trapped: balloon dissection of left main coronary artery successfully managed with bailout stenting—a case report

Abrupt left main coronary artery (LMCA) closure from ruptured balloon during percutaneous coronary intervention is rare and can be catastrophic. A comprehensive knowledge of the various bailout techniques in such situations can be life-saving. We describe a case of abrupt left main vessel closure leading to haemodynamic instability and the techniques employed for a prompt and successful revascularization.

A 74-year-old gentleman presented with effort angina. His trans-radial coronary angiogram revealed significant LMCA stenosis with triple vessel disease. While attempting to prepare the left circumflex (LCx) artery lesion with balloon dilatation, balloon rupture led to retrograde LMCA dissection with abrupt vessel closure and haemodynamic instability. Subsequently, bailout stenting from LMCA to left anterior descending artery was done followed by TAP stenting (T And small Protrusion) to LCx, thereby compressing the remanent balloon fragment against the vessel wall of the LCx (crush technique) and achieving TIMI III (Thrombolysis in Myocardial Infarction) flow.

This case highlights the catastrophic complication of abrupt LMCA closure with remanent balloon fragment that may occur with balloon rupture. Recognizing the various factors that lead to balloon rupture is important. Establishing LMCA perfusion while maintaining haemodynamics should be the primary goal in patients with acute LMCA occlusion. Bailout stenting decreases the time lapse and subsequent prolonged ischaemia with worsening left ventricular function compared to coronary artery bypass grafting.