Arterial perforation (by balloon) during subintimal angioplasty.

Perforation complicates 3–4% of angioplasties and can be treated by temporary balloon occlusion, coil embolisation, placement of a covered stent or redissection past the perforation using the subintimal angioplasty technique. Our unit has generally been reluctant to place covered stents in the infra-inguinal region, largely because of concerns about in-stent restenosis. Most perforations occurring during subintimal angioplasty (a modification of the traditional angioplasty technique) follow manipulation of the guide wire in the extra-luminal space. A relative minority occur during balloon inflation. It has previously been our experience that arterial perforation does not worsen outcome following angioplasty and we have, therefore, never recommended post-procedural ultrasound surveillance. We report a case of a successfully treated perforation occurring during subintimal angioplasty. The perforation occurred during balloon insufflation of the subintimal channel and then presented secondarily with a large, symptomatic false aneurysm. Awareness of this case has led to a revision of our post-procedural surveillance strategy.