Implementation of the kissing balloon technique using a perfusion balloon in acute myocardial infarction: a case report

Abstract

Background

Prolonged antiplatelet-agent administration associated with stenting for acute myocardial infarction is not ideal in young patients. We successfully performed a perfusion balloon-based kissing balloon technique in the left anterior descending artery ostium in a young patient with acute myocardial infarction.

Case summary

A 34-year-old female presenting with recurrent chest pain was diagnosed with ST-segment elevation acute myocardial infarction. Emergency coronary angiography revealed 90% stenosis of the left anterior descending artery ostium. Considering her age, lesion dilation using a perfusion balloon was preferred. This inadvertently impinged the left circumflex artery, causing chest pain and ischaemia-related hypotension with only a 10 s perfusion dilation balloon. We transitioned to an alternative 7 Fr guiding catheter and performed the kissing balloon technique using a perfusion balloon. This allowed prolonged inflation for 120 s, without complications. Optical coherence tomography of the lesion revealed layered plaques. Based on the patient’s age and medical history, coronary spasm may be the aetiological factor underlying acute ST-segment elevation myocardial infarction. Coronary angiography 3 months post-discharge revealed no restenosis.

Discussion

Regarding acute myocardial infarction, prolonged inflation with a perfusion balloon had higher frequency of non-stent-related interventions than that of semi-compliant or non-compliant balloons. In this case, the perfusion balloon resulted in chest pain and hypotension. Perfusion balloon-based kissing balloon technique was useful in this setting. Optical coherence tomography revealing the responsible lesions can help determine the cause of acute myocardial infarction in young patients; in our case, a layered plaque was observed. Layered plaques are associated with coronary spasm; therefore, initiating treatment of coronary spasm was considered herein.

Learning points.

Case: A young female with acute myocardial infarction (AMI) in whom stent deployment was to be avoided was treated by perfusion balloon kissing balloon technique (KBT).

• To safeguard adequate blood flow to the left circumflex artery (LCX) when the culprit lesion is situated at the left anterior descending artery ostium and a perfusion balloon inadvertently obstructs blood flow to the LCX, perfusion balloon KBT is useful.

• To facilitate optimal medical therapy, identifying the underlying AMI cause, such as by optical coherence tomography, is imperative, particularly in young patients.

Introduction

Stenting represents a prevalent intervention for acute myocardial infarction (AMI), necessitating prolonged administration of antiplatelet agents post-implantation. Stenting should be avoided in younger patients to preserve the possibility of discontinuing administration of antiplatelet agents. Prolonged inflation of the culprit lesion using a perfusion balloon during AMI enhances the probability of achieving a stent-free outcome.¹ Herein, we describe a case of successful implementation of a perfusion balloon-based kissing balloon technique (KBT) in a young patient with AMI.

Summary figure

Time	Event
1 month before admission	Patient experienced recurrent chest pain, radiating from the jaw and the left shoulder, lasting ∼5 min, every 2–3 days, regardless of rest or exertion.
1 h before admission	Patient experienced chest pain during rest, pain continued longer than usual; an ambulance was requested.
At admission	Chest pain ceased just after admission. ECG showed no ischaemic change.
1 h after admission	Chest pain recurred. ECG revealed ST-segment elevation at aVR lead and diffuse ST-segment depression in multiple leads. Emergency coronary angiography was performed.

Case presentation

A 34-year-old woman with a history of bronchial asthma and irregular medical visits presented with recurrent chest pain occurring every 2–3 days, first experienced a month ago. The pain radiated from the jaw and left shoulder, lasting ∼5 min, unaffected by rest or exertion. The patient, resting at home during a prolonged episode of chest pain, was subsequently transported to the hospital via ambulance. Patient’s height, weight, and body mass index were 160 cm, 106.7 kg, and 41.7 kg/m², respectively. Patient’s blood pressure, pulse, respiratory rate, and oxygen saturation (ambient air) were 165/87 mmHg, 90 beats/min, 18 breaths/min, and 98%, respectively. Physical examination revealed no abnormal cardiac or respiratory auscultatory sounds. Laboratory test results are presented in Table 1. Only at that time, untreated diabetes mellitus and dyslipidaemia were discovered.

Table 1.

Laboratory investigations at initial visit

Parameter	Value at initial visit	Normal range
White blood cell count (cells/µL)	14 600	3300–8600
Haemoglobin (g/dL)	13.2	11.6–14.8
Platelet count (/µL)	37.7 × 104	15.8–34.8 × 104
Total bilirubin (mg/dL)	0.2	0.4–1.5
Aspartate aminotransferase (U/L)	29	13–30
Alanine aminotransferase (U/L)	36	7–23
Lactase dehydrogenase (U/L)	213	124–222
ɤ-Glutamyl transpeptidase (U/L)	69	9–32
Blood urea nitrogen (mg/dL)	9.7	8.0–22.0
Creatinine (mg/dL)	0.46	0.46–0.79
Sodium (mEq/L)	137	138–145
Potassium (mEq/L)	4.3	3.6–4.8
Chloride (mEq/L)	101	101–108
Glucose (mg/dL)	178	73–109
HbA1c (%)	7.8	4.9–6.0
Total cholesterol (mg/dL)	199	142–248
Triglycerides (mg/dL)	250	30–117
HDL cholesterol (mg/dL)	44	48–103
LDL cholesterol (mg/dL)	128	65–163
D-dimer (µg/mL)	0.5	<1.0
Hs-TnT (pg/mL)	38	0–26

HDL, high-density lipoprotein; LDL, low-density lipoprotein; Hs-TnT, high sensitivity cardiac troponin T.

The abnormal values are bolded.

Initial electrocardiogram (ECG) upon arrival showed no abnormalities (Figure 1A). However, 1 h post-administration, she again experienced chest pain: an ECG showed ST-segment elevation in the aVR lead and diffuse ST-segment depression in multiple leads (Figure 1B), leading to the diagnosis of ST-segment elevation AMI (STEMI). Emergency coronary angiography from the left radial artery for STEMI revealed 90% stenosis of the left anterior descending artery (LAD) ostium (Figure 2A). Considering her right-handedness and the undesirable nature of puncture site complications in the dominant hand, we punctured the left radial artery. Despite intracoronary nitroglycerine administration, stenosis persisted, necessitating percutaneous coronary intervention. We inserted a 6 Fr guiding catheter; wire easily crossed the lesion. Optical coherence tomography (OCT) revealed a thrombus within the left main coronary artery trunk, with a substantial thrombotic burden in the most stenotic segment (Figure 3A–C), and a layered plaque slightly distal to the thrombus (Figure 3D and E). No evidence of plaque rupture was noted. We did not perform thrombus aspiration, because we thought thrombus volume was small. Considering her youth, we decided to minimize stent use and dilated the lesion using a perfusion balloon (Figure 2B). However, this inadvertently impinged the left circumflex artery (LCX), causing chest pain and ischaemia-related hypotension. We performed a double-guiding catheter approach to an alternative 7 Fr guiding catheter through the right radial artery and performed the KBT using a perfusion balloon (Figure 2C and Supplementary material online, Video S1). This allowed prolonged (120 s) inflation, without provoking chest pain or blood pressure decrease. Optical coherence tomography demonstrated successful thrombus reduction (Figure 3A′–C′) and acute lumen gain (Figure 3D′ and E′). Finally, a drug-coated balloon (SeQuent Please Neo, BBraun Medical, Melsungen, Germany; LAD: 3.5 × 20 mm; LCX: 3.0 × 20 mm) was used for the KBT for 40 s. The fact that blood pressure did not decrease and chest pain did not occur during the 40 s of KBT may be due to ischaemic preconditioning. Post-intervention coronary angiography confirmed TIMI grade 3 blood flow restoration (Figure 2D).

Figure 1.

Electrocardiograms. (A) Initial electrocardiogram performed upon hospital admission. The ST-segment shows no discernible alterations. (B) One hour post-admission, electrocardiogram taken in response to the patient’s reported chest discomfort shows ST-segment elevation in the aVR lead, and ST-segment depression in the other leads.

Figure 2.

Coronary angiography. (A) Coronary angiography performed for ST-elevation myocardial infarction reveals a 90% stenosis at the left anterior descending artery (LAD) segment 6 ostium. (B) We dilated the culprit lesion using a perfusion balloon (3.5 × 20 mm). (C) Kissing balloon technique with a perfusion balloon (LAD: 3.5 × 20 mm, left circumflex artery: 3.0 × 20 mm). (D) Final angiography.

Figure 3.

Optical coherence tomography findings. A–E show findings from the left main trunk (LMT) to the left anterior descending artery (LAD), with 0.4 mm increments between points. A–C show the thrombus from the LMT to the LAD ostium. D and E do not exhibit typical thrombus morphology. These regions feature healed plaques, distinguished by the presence of a well-defined layer of organized thrombus and/or collagen. Aʹ–Eʹ demonstrate successful thrombus reduction and acute lumen gain.

Discussion

Only 1–6% of all AMI cases involve individuals < 40 years of age.² Although stent placement is a standard AMI treatment, it must be used carefully in young patients due to the inherent associated requirement for lifelong antiplatelet therapy. In patients with acute coronary syndromes, prolonged inflation with a perfusion balloon has a reduced incidence of no-reflow and slow-flow, and a higher frequency of non-stent-related interventions than that of semi-compliant or non-compliant balloons.¹ We attempted extended inflation using the Ryusei perfusion balloon (KANEKA Medix Corp.). Ryusei is a specialized device designed to ensure coronary artery blood flow concomitant with balloon dilation. It was developed to ensure haemostasis and secure coronary blood flow through balloon dilation in cases of coronary artery perforation. However, its utility extends beyond, as in our case, where it is employed for thrombus treatment in myocardial infarction scenarios. The operational mechanism involves strategically positioned perfusion holes both anterior and posterior to the balloon, facilitating the unimpeded passage of blood (Figure 4). The coronary flow to the periphery during Ryusei balloon dilation relies on factors such as blood pressure, guiding catheter placement (whether shallow or deep), and applied pressure during balloon dilation. In vitro experiments revealed that at 14 atm, also the rated balloon pressure, the balloon sustained perfusion to its peripheral exceeding 30 mL/min, leading to its marketing approval by Pharmaceuticals and Medical Devices Agency (PMDA). However, the perfusion balloon extended into the left main trunk (LMT) due to stenosis in the proximal LAD, subsequently causing LCX territory ischaemia, resulting in chest pain and hypotension. As two perfusion balloon could not be accommodated in 7 Fr guiding catheters, we implemented a double-guiding catheter approach, which allowed us to perform a perfusion balloon-based KBT successfully. This effectively expanded the lesion within the LAD ostium, while concurrently mitigating LCX ischaemia. Although the use of a perfusion balloon in the LCX may differ from its intended application, this case has demonstrated that performing perfusion balloon-based KBT on the bifurcation lesion of the LMT could ensure blood flow in both the LAD and LCX.

Figure 4.

Structure of Ryusei perfusion balloon. The balloon’s proximal section features a vertical row of 16 holes spaced 1 mm apart, allowing blood to flow through them during balloon dilation. Conversely, the distal portion of the balloon is equipped with eight holes distributed evenly around its circumference, facilitating blood outflow through these openings. Balloon length is 20 mm only, and balloon diameters are 2.5, 3.0, 3,5, and 4.0 mm.

If it were adapted to a single guiding catheter, an 8 Fr guiding catheter would be needed, mandating femoral artery puncture. Particularly in patients with obesity, such as our case, femoral artery puncture can prove challenging and increases puncture site complication risks and presents challenges in achieving effective haemostasis. Employing vascular echocardiography during femoral artery puncture can potentially reduce complications.³ This approach has also been documented as suitable for individuals with obesity.⁴ Nevertheless, femoral artery puncture is associated with a higher frequency of complications at the puncture site when compared with that with radial artery puncture. Regarding STEMI treatment, radial artery puncture is recommended.⁵ To minimize vascular injury, we utilized a 7 Fr Glidesheath Slender (TERUMO) from right radial artery. This sheath features a thin-wall construction designed to maintain the inner diameter while reducing the outer diameter by 1 Fr. Essentially, it is engineered to facilitate the insertion of a 7 Fr guiding catheter through a 6 Fr sheath.

In young AMI cases, potential aetiological factors include congenital anomalies and anatomical blood vessel irregularities, coronary artery dissection, coronary spasm, and inflammatory conditions, such as Kawasaki disease.⁶ Among women younger aged <50 years who experience myocardial infarction, atherosclerotic plaque is responsible for 42% of cases, idiopathic coronary artery dissection for 35%, and vasospasm for 10%.⁷ The patient in question may have harboured an underlying condition known as Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). The diagnosis of MINOCA necessitates the presence of clinical evidence indicative of AMI, coupled with the absence of coronary artery stenosis exceeding 50%. MINOCA can stem from various aetiologies, encompassing spasm and disruption in atherosclerotic plaques.⁸ In our case, OCT revealed a layered plaque (Figure 3D and E) and thrombus without plaque rupture (Figure 3A–C). Approximately 28.7% of patients presenting with acute coronary syndrome exhibit layered plaque, which tend to be fragile and manifest as localized and systematic inflammation.⁹ When employing OCT to investigate organic lesions, layered plaques, macrophages, and intraplaque microchannels were observed more frequently in patients with than in patients without coronary spasms.¹⁰ Considering the patient’s clinical history, marked by chest pain, irrespective of rest or exertion, and the OCT-confirmed presence of layered plaques, we postulated that she had coronary spasm. Although spasm can be induced by hormonal imbalances associated with pregnancy or by exogenous vasospastic agents such as cocaine or methamphetamines,⁸ these factors were absent in her. We proposed provocative spasm testing to definitively diagnose spasm involvement, yet she declined such an evaluation.

The emergence of STEMI in this case may be attributed to two conceivable mechanisms. First, MINOCA ensued due to spasm, coupled with the gradual progression of organic stenosis resulting from layered plaques. The subsequent spasm led to a reduction in coronary blood flow, fostering thrombus formation. Second, the manifestation of plaque erosion, a consequence of atherosclerosis, was evident. The patient, with untreated diabetes mellitus, had a predisposition to atherosclerosis. It was contemplated that both atherosclerotic plaque erosion and spasm contributed to the current clinical presentation, prompting the initiation of dual antiplatelet therapy (aspirin, one 100 mg tablet daily, prasugrel 3.75 mg tablet daily) and statin (atorvastatin, one 20 mg tablet daily) therapy for addressing atherosclerotic plaque erosion, and a calcium channel blocker (nifedipine, one 20 mg tablet twice daily) for managing spasm. Although aspirin was deemed necessary for enduring secondary prophylaxis,⁵ the absence of stent implantation alleviated concerns regarding stent thrombosis, thereby allowing for the possibility of aspirin withdrawal. Additionally, the option for temporary discontinuation of aspirin was preserved in cases of major bleeding due to various reasons, such as unforeseen accidents or childbirth. In this case, the stent was deployed up to the LMT due to thrombus and plaque presence at the LAD ostium. However, concerns regarding stent restenosis and stent thrombosis arose upon stent implantation. Although drug-eluting stents have reduced restenosis occurrence compared with bare metal stents, it is present in 2–10% of cases.¹¹ Restenosis symptoms typically include recurring chest pain and heart failure, with 10% of patients experiencing myocardial infarction.¹¹ Given the patient’s history of diabetes and obesity in this report, which increase stent restenosis risk,¹² opting for a non-stenting approach was deemed necessary. In the absence of OCT findings, the assumption of spasm involvement remains speculative. Nonetheless, calcium channel blockers assume significance as pivotal agents that enhance survival in patients afflicted with vasospastic angina.¹³ At check-up one month later, she did not report any chest pain, and her LDL-C had dropped to 53 mg/dL.

Lead author biography

Marohito Nakata graduated from Kurume University and currently functions as a cardiologist at Urasoe General Hospital, specializing in percutaneous coronary intervention and demonstrating an interest in the intervention of chronic total occlusion.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

 

Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.

Funding: This research received no external funding.

Data availability

The data underlying this article will be shared upon reasonable request to the corresponding author.