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P M T Pattynama

Publications and source records attributed to P M T Pattynama.

16 recordsLinked to original sources
PubMed2006

[Right-ventricular dysfunction and the pulmonary vascular obstruction index: predictable variables of the clinical course over 3 months in patients with acute lung emboli].

OBJECTIVE: To quantify right-ventricular dysfunction and the pulmonary artery obstruction index, in patients with acute pulmonary embolism, using helical CT, and to assess the prognostic value of these parameters. DESIGN: Prospective. METHOD: In 120 consecutive patients with proven acute pulmonary embolism, the extent of right-ventricular dysfunction was assessed by quantifying the ratios of the right to left-ventricular short-axis diameters (RV/LV ratio) and the extent ofobstruction ofthe pulmonary-artery circulation by using helical CT images. Regression analysis was used to correlate these parameters with patient outcome. RESULTS: Right-ventricular dysfunction (RV/LV ratio > 1.0) was seen in 69 patients (57.5%). Seven patients died as a direct result of pulmonary embolism. Both the RV/LV ratio and the obstruction index were significant risk factors for mortality within three months (p = 0.04 and 0.01 respectively). The positive predictive value for pulmonary embolism-related mortality of an RV/LV ratio > 1.0 was 10.1% (95% CI: 2.9-17.4). The negative predictive value for an uneventful outcome of an RV/LV ratio < or = 1.0 was 100% (95% CI: 94.3-100). There was a 11.2-fold risk of dying of pulmonary embolism in patients with an obstruction index > or = 40% (95% CI: 1.3-93.6). CONCLUSION: Markers of right-ventricular dysfunction and pulmonary vascular obstruction, assessed by helical CT-examination at baseline, help to predict mortality during follow-up of patients with acute pulmonary embolism.

Acute Disease↗
PubMed2006

[Complications within 30 days following placement of a carotid stent with cerebral protection in patients with considerable symptomatic carotid stenosis; Erasmus MC, Rotterdam, 1999-2004].

OBJECTIVE: To describe the complications that occur within 30 days following the placement of a stent in the carotid artery in patients with considerable symptomatic carotid stenosis. DESIGN: Retrospective. METHOD: Data were collected on 98 patients who received a carotid stent due to symptomatic carotid stenosis of > or = 70% of the lumen at the Erasmus MC, Rotterdam, the Netherlands, in the years 1999-2004. A filter, distal occlusion balloon or the Parodi anti-embolism system was used to prevent cerebral embolism. Outcome measures were complications within 30 days following intervention. RESULTS: Four patients were excluded in the period between diagnosis and stenting. Major complications occurred in 3 patients: 1 died due to cerebral haemorrhage and 2 experienced cerebral infarction. Transient neurological complications occurred in 4 patients who recovered completely. Dissection of the renal artery occurred in 1 patient, which necessitated a stent. Vascular damage of the internal carotid artery was not observed in any patient. The 3 major adverse events and 3 of the 4 minor adverse events occurred in the first 47 patients treated. None of the last 47 patients treated developed major adverse events.

Aged↗
PubMed2006

Lung tumor tracking during stereotactic radiotherapy treatment with the CyberKnife: Marker placement and early results.

Lung tumor tracking during stereotactic radiotherapy with the CyberKnife requires the insertion of markers in or close to the tumor. To reduce the risk of pneumothorax, three methods of marker placement were used: 1) intravascular coil placement, 2) percutaneous intrathoracal, and 3) percutaneous extrathoracal placement. We investigated the toxicity of marker placement and the tumor response of the lung tumor tracking treatment. Markers were placed in 20 patients with 22 tumors: 13 patients received a curative treatment, seven a palliative. The median Charlson Comorbidity Score was 4 (range: 1-8). Platinum fiducials and intravascular embolisation coils were used as markers. In total, 78 markers were placed: 34 intrathoracal, 23 intravascular and 21 extrathoracal. The PTV equaled the GTV + 5 mm. A median dose of 45 Gy (range: 30-60 Gy, in 3 fractions) was prescribed to the 70-85% isodose. The response was evaluated with a CTscan performed 6-8 weeks after the last treatment and routinely thereafter. The median follow-up was 4 months (range: 2-11). No severe toxicity due to the marker placement was seen. Pneumothorax was not seen. The local control was 100%. Four tumors in four patients showed a complete response, 15 tumors in 14 patients a partial response, and three tumors in two patients with metastatic disease had stable disease. No severe toxicity of marker placement was seen due to the appropriate choice of one of the three methods. CyberKnife tumor tracking with markers is feasible and resulted in excellent tumor response. Longer follow-up is needed to validate the local control.

Adult↗
PubMed2006

Shrinkage of abdominal aortic aneurysm after successful endovascular repair: results from single center study.

AIM: In the literature, the behavior of the aneurysm sac after endovascular grafting has been the subject of significant speculation. It has been suggested that shrinkage of the abdominal aortic aneurysm (AAA) is different for various endografts. This study was undertaken to evaluate endograft-specific differences in aneurysm sac shrinkage and to evaluate other factors that may influence AAA shrinkage. METHODS: Forty patients with an AAA treated with endovascular grafts with a complete 18 months follow-up and complete CT angiography (CTA) follow-up were available for analysis. All patients with a persistent endoleak, endograft migration or any other reason for intervention or conversion were excluded from this analysis. Shrinkage was defined as a reduction in the AAA diameter of 5 mm or more. Chi-squared tests were used to test whether shrinkage was different for the kind of stent graft used (Gore Excluder vs Cook-Zenith), preexistent AAA diameter (<65 mm vs =or>65 mm), and AAA status (ruptured vs non-ruptured) (two-sided; a= 0.05). RESULTS: At 18 months after treatment, shrinkage was observed in 14 patients (52%) of the 27 patients treated with a Gore Excluder endograft and in 8 patients (62%) of the 13 patients treated with a Cook Zenith endograft (P=0.74). In 31 patients with a diameter <65 mm, shrinkage was observed in 19 patients (61%) whereas of the 9 patients with a diameter =or>65 mm, shrinkage was observed in 3 patients (33%) (P=0.253). Of the 34 patients with a non-ruptured AAA, shrinkage was observed in 18 patients (53%) versus of the 6 patients with a ruptured AAA shrinkage was observed in 4 patients (66%) (P=0.673). CONCLUSIONS: From this study can be concluded that the influence of the endograft on shrinkage of the AAA sac might be less prominent than suggested in the literature. Furthermore, our study shows that other factors such as preexistent AAA diameter may influence AAA shrinkage after endovascular repair.

Aged↗
PubMed2005

[The diagnosis of pulmonary embolism: the best strategies according to the results of a large Dutch multicentre study].

The Dutch national guidelines for the diagnosis of patients with clinically suspected pulmonary embolism (from 1992 en 1998) are poorly followed in clinical practice, due especially to practical objections. A large multicentre trial to investigate the diagnostic accuracy of the available modalities and of recently developed techniques such as D-dimer determination, (99m)Tc-gas-scintigraphy and spiral CT scanning was started in I997. In the first phase, the diagnostic value was assessed of: spiral CT (sensitivity 69%, specificity 84%; sensitivity for segmental and larger pulmonary embolisms (PE) 86% and for subsegmental PE 21%), (99m)Tc-gas-ventilation scintigraphy (no improvement compared to conventional ventilation scintigraphy), D-dimer determination (sensitivity for segmental PE 93% and for subsegmental PE 53%, specificity 63%), clinical decision rules (in combination with D-dimer determination; sensitivity 100%, specificity 11%) and echography of the deep venous system (sensitivity 26% for segmental PE and 7% for subsegmental PE, specificity 97%). In the second phase, the feasibility of two new potentially cost-effective diagnostic algorithms was evaluated on the basis of the results obtained in the first phase and data in the literature. In 631 patients, a clinical risk estimate was made and D-dimer determination was done, followed by a ventilation-perfusion scan and serial compression echography of the leg veins. An apparent recurrence of PE occurred in 6 of 466 patients in whom no PE had been found originally (1.3%; 95% CI: 0.5-2.8). The average costs were 812 Euro,--per patient. In 510 patients, a spiral CT followed by compression echography was performed. Recurrent PE occurred in 3 of 378 patients with initial normal tests (0.8%; 95% CI: 0.2-2.3). The average costs were 883 Euro,--per patient. A combination of both strategies can be cost-effective with a cost 674 Euro,--per patient (recurrence rate: 1.9%). Both the strategy starting with a clinical-risk estimate and a D-dimer determination as well as the strategy consisting of spiral CT and serial echography were safe and cost-effective. According to the results of a survey of hospital directors, internists and pulmonologists, both are well accepted in clinical practice.

Algorithms↗
PubMed2005

Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy.

BACKGROUND: Spiral computed tomography (CT) has emerged as a potentially conclusive diagnostic test to exclude pulmonary embolism (PE) in patients with non-high probability scintigraphy and is already widely used-sometimes as the sole primary diagnostic test in the diagnosis of suspected PE. Its true sensitivity and specificity has, however, not been evaluated previously in a large cohort of consecutive patients. METHODS: In a multicenter prospective study 627 consecutive patients with clinically suspected PE were studied. Patients with normal perfusion scintigraphy were excluded from further analysis. Single-detector spiral CT scanning and ventilation scintigraphy were then performed in all patients to diagnose PE, while pulmonary angiography was performed as the gold standard. The only exceptions were those patients who had both a high-probability VQ scan and a CT scan positive for PE: these patients were considered to have PE and did not undergo additional pulmonary angiography. All imaging tests were read by independent expert panels. RESULTS: Five hundred and seventeen patients were available for complete analysis. The prevalence of PE was 32%. Spiral CT correctly identified 88 of 128 patients with PE, and 92 of 109 patients without PE, for a sensitivity and specificity of 69%[95% confidence interval (CI) 63-75] and 84% (95% CI 80-89), respectively. The sensitivity of spiral CT was 86% (95% CI 80-92) for segmental or larger PE and 21% (95% CI 14-29) in the group of patients with subsegmental PE. CONCLUSION: The overall sensitivity of spiral CT for PE is too low to endorse its use as the sole test to exclude PE. This holds true even if one limits the discussion to patients with larger PE in segmental or larger pulmonary artery branches. We conclude that, in patients with clinically suspected PE and an abnormal perfusion scintigraphy, single-slice detector spiral CT is not sensitive enough to be used as the sole test to exclude PE.

Adult↗
PubMed2005

Helical computed tomography and alternative diagnosis in patients with excluded pulmonary embolism.

OBJECTIVE: A clinical diagnosis of pulmonary embolism (PE) is confirmed objectively in 20-30% of patients. Helical computed tomography (CT) can allow an alternative diagnosis to be made. The frequency and validity of alternative diagnoses on helical CT in consecutive patients presenting with clinically suspected PE was assessed. PATIENTS AND METHODS: In all 512 prospectively analyzed patients helical CT scan was performed, and apart from presence or absence of PE, pathologic changes in lung parenchyma, mediastinum, cardiovascular system, pleura and skeleton were recorded. When possible an alternative diagnosis was given and compared with the final diagnosis after 3 months follow-up. RESULTS: In 130 patients (25.4%) PE was excluded and an alternative diagnosis considered likely. In 123 of the 130 patients (94.6%) this diagnosis was unchanged at 3 months follow-up. The diagnoses included pneumonia (n = 67), malignancy (n = 22), pleural fluid (n = 10), cardiac failure (n = 10), COPD (n = 6) and a variety of other causes (n = 15). The diagnosis changed at follow-up in seven patients (5.4%). An initial diagnosis of pneumonia changed to malignancy in two patients and to pleuritis and cardiac failure in one patient each. In two other patients malignancy and chronic obstructive pulmonary disease (COPD) were ruled out and the diagnosis changed to pneumonia. In one patient the final diagnosis remained unknown after an initial suspicion of malignancy. CONCLUSION: In clinically suspected PE helical CT allows a reliable alternative diagnosis to be made in 25.4% of patients. This feature is an unique advantage in comparison with other diagnostic tests and supports the decision of taking helical CT as first line test in suspected PE.

Algorithms↗
PubMed2005

Non-invasive diagnosis of pulmonary embolism, anno 2005.

Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of >99% : a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value is 85 to 88% for a high probability ventilation-perfusion lung scan (VP-scan) and >95% for helical spiral CT. The prevalence of PE in management studies of symptomatic patients with a non-diagnostic VP-scan is 20 to 24%. Helical spiral CT detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic VP-scan or a high probability VP-scan. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in three retrospective studies and in two prospective management study indicate that the negative predictive value of a normal helical spiral CT, a negative compression ultrasonography of the legs (CUS) together with a low or intermediate pre-test clinical probability is >99%. Therefore, helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40 to 50%.

Angiography↗
PubMed2005

A critical appraisal of non-invasive diagnosis and exclusion of deep vein thrombosis and pulmonary embolism in outpatients with suspected deep vein thrombosis or pulmonary embolism: how many tests do we need?

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism of less than 1% during 3 month follow-up. Compression ultrasonography (CUS) has a negative predictive value (NPV) of 97% to 98% indicating the need of repeated CUS testing. Serial CUS testing is safe but you have to repeat 100 CUS to find 1 or 2 CUS positive for deep vein thrombosis (DVT), which is not cost-effective indicating the need to improve the diagnostic work-up of DVT by the use of clinical score assessment and D-dimer testing. The combination of a less sensitive D-dimer test (SimpliRed) and low clinical score does not, whereas the combination of a sensitive D-dimer test (ELISA VIDAS or Tinaquant) and low clinical score does safely exclude DVT without the need of CUS. The combination of a first negative CUS and a negative less sensitive D-dimer test (SimpliRed) or a sensitive ELISA D-dimer at a higher cut off level of 1,000 ng/ml safely excludes DVT with a NPV of > 99% without the need to repeated CUS in about 60%. The sequential use of a sensitive D-dimer and clinical score assessment will safely reduce the need for CUS testing by 40% to 60%. Large prospective outcome studies demonstrate that one negative examination with complete duplex color ultrasonography (CCUS) of the proximal and distal veins of the affected leg with suspected DVT is safe to withhold anticoagulant treatment with a NPV of 99.5%. This indicates that CCUS is equal or superior to serial CUS or the combined use of clinical score, D-dimer testing and CUS. Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but not for subsegmental PE. A normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test safely exclude PE. Helical spiral CT detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic ventilation perfusion scan (VP-scan) or a high probability VP-scan. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in 5 retrospective studies and in 3 prospective management studies indicate that the NPV of a normal helical spiral CT, a negative CUS of the legs together with a low or intermediate pretest clinical probability is 99%. Helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40% to 50%.

Ambulatory Care↗
PubMed2003

Interstitial laser coagulation with temporary hepatic artery occlusion for patients with cirrhosis and irresectable hepatoma.

BACKGROUND: The aim was to determine the degree of local control of hepatocellular carcinoma (HCC) in patients with cirrhotic liver disease when treated with ultrasonographically guided interstitial laser coagulation (ILC) with temporary hepatic artery occlusion. METHODS: Sixteen patients with 24 HCC tumours were treated. Follow-up was by computed tomography or magnetic resonance imaging every 3 months. RESULTS: Nineteen of 24 tumours showed complete necrosis immediately after treatment, and there was no tumour recurrence during follow-up (mean 14 months, median 12 months). No effect on liver function was observed after 1 week and there was no death. In 13 of the 16 patients, new HCC foci developed at other sites. CONCLUSION: Percutaneous ILC combined with temporary hepatic artery occlusion during a single session is an effective local treatment for HCC nodules smaller than 5 cm. However, new HCC lesions develop in the majority of patients, which underscores the need for adjuvant therapy or repeated treatment in these patients.

Aged↗
PubMed2003

Non-invasive exclusion and diagnosis of pulmonary embolism by sequential use of the rapid ELISA D-dimer assay, clinical score and spiral CT.

Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for its subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of > 99%: a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value of a high probability ventilation-perfusion lung scan (VP-scan) is only 85% to 87%. The combination of a low clinical score and a non-diagnostic VP-scan safely exclude PE without the need of angiography. The prevalence of PE and that of an alternative diagnosis in symptomatic patients with a non-diagnostic VP-scan are 10% to 20% and 30% to 45%, respectively. Helical spiral computed tomography (CT) detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or high probability VP-scan. The positive predictive value of the spiral CT is > 95%. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in retrospective outcome studies and in prospective multicenter management studies indicate that the negative predictive value of a negative spiral CT preceded or followed by a negative compression ultrasonography (CUS) is > 99%. Therefore, a helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. A negative rapid ELISA VIDAS D-dimer test result will reduce the need for helical spiral CT by 25% to 35%.

Aged↗
PubMed2002

Gamma radiation induces positive vascular remodeling after balloon angioplasty: a prospective, randomized intravascular ultrasound scan study.

BACKGROUND: Endovascular brachytherapy (EBT) has been shown to prevent restenosis after percutaneous transluminal coronary angioplasty (PTA) in both animal and clinical studies. However, as yet, the effect of EBT on peripheral arteries is unknown. OBJECTIVE: This intravascular ultrasound scan (IVUS) study evaluates the effect of EBT on the extent of plaque growth and vascular remodeling after PTA of the femoropopliteal artery. METHODS: Twenty-four patients with obstructive disease of the femoropopliteal artery underwent standard PTA. Patients were randomized to receive no additional therapy or additional EBT (192-Iridium) after PTA. IVUS investigation was performed after PTA and at 6-month follow-up. A comparison was made between patients without EBT (n = 16) and with EBT (n = 8) in the change in lumen, vessel, and plaque area and plaque dissections seen with IVUS at 6-month follow-up. RESULTS: At follow-up, IVUS revealed a significant difference in lumen area change between patients without and with EBT (-9% and +23%, respectively; P =.03). This difference was the result of a significant difference in vessel area change (+2% and +19%, respectively; P =.05). In both groups of patients, a similar increase in plaque area (+12% and +16%, respectively; P =.80) was encountered. Plaque dissections encountered immediately after PTA were absent at follow-up in patients without EBT, whereas in four of the eight patients with EBT, a persistent dissection was encountered. CONCLUSION: This randomized IVUS study showed that gamma-radiation after PTA has a positive effect on lumen dimensions at 6-month follow-up by inducing positive vascular remodeling (ie, vascular dilatation); gamma-radiation seemed not to affect plaque growth. In addition, gamma-radiation has an effect on the healing process of dissections after PTA.

Adult↗
PubMed2002

Non-invasive coronary angiography with multislice spiral computed tomography: impact of heart rate.

OBJECTIVE: To evaluate the impact of heart rate on the diagnostic accuracy of coronary angiography by multislice spiral computed tomography (MSCT). DESIGN: Prospective observational study. PATIENTS: 78 patients who underwent both conventional and MSCT coronary angiography for suspicion of de novo coronary artery disease (n=53) or recurrent coronary artery disease after percutaneous intervention (n=25). SETTING: Tertiary referral centre. METHODS: Intravenously contrast enhanced MSCT coronary angiography was done during a single breath hold, and ECG synchronised images were reconstructed retrospectively. All coronary segments of > or = 2.0 mm without stents were evaluated by two investigators and compared with quantitative coronary angiography. Patients were classified according to the average heart rate (mean (SD)) into three equally sized groups: group 1, 55.8 (4.1) beats/min; group 2, 66.6 (2.8) beats/min; group 3, 81.7 (8.8) beats/min. RESULTS: Image quality was sufficient for analysis in 78% of the coronary segments in patients in group 1, 73% in group 2, and 54% in group 3 (p < 0.01). The sensitivity and specificity for detecting significant stenoses (> or = 50% lumen reduction) in these assessable segments were: 97% (95% confidence interval (CI) 84% to 100%) and 96% in group 1; 74% (52% to 89%) and 94% in group 2; and 67% (33% to 90%) and 94% in group 3 (p < 0.05). Accounting for all segments of > or = 2.0 mm, including lesions in non-assessable segments as false negatives, the sensitivity decreased to 82% (28/34 lesions, 95% CI 69% to 91%), 61% (14/23 lesions, 42% to 77%), and 32% (6/19 lesions, 15% to 50%), respectively (p < 0.01). CONCLUSIONS: MSCT allows reliable coronary angiography in patients with low heart rates.

Confidence Intervals↗
PubMed2002

Shrinkage of the distal renal artery 1 year after stent placement as evidenced with serial intravascular ultrasound.

The objective of this study was to determine the quantitative intravascular ultrasound (IVUS) and angiographic changes that occur during 1 year follow-up after renal artery stent placement, given that restenosis continues to be a limitation of renal artery stent placement. 38 consecutive patients with symptomatic renal artery stenosis treated with Palmaz stent placement were studied prospectively. IVUS and angiography were performed at the time of stent placement and at 1 year follow-up. At follow-up, angiographic restenosis was seen in 14% of patients. The lumen area in the stent, seen with IVUS, was significantly decreased from 24+/-5.6 mm(2) to 17+/-5.6 mm(2) (p<0.001) solely due to plaque accumulation. The distal main renal artery showed a significant decrease in lumen area owing to a significant vessel area decrease from 39+/-14.0 mm(2) to 29+/-9.3 mm(2) (p<0.001) without plaque accumulation. Angiographic analysis confirmed this reduction in luminal diameter and showed that the distal renal artery diameter at follow-up was significantly smaller than before stent placement (86+/-23.0% vs 104+/-23.9% of the contralateral renal artery diameter; p=0.003). Besides plaque accumulation in the stent, unexplained shrinkage of the distal main renal artery was evidenced with IVUS and angiography 1 year following stent placement.

Aged↗
PubMedDate not supplied

The benefit of STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery. The STAR-study: rationale and study design.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with progressive loss of renal function and is one of the most important causes of renal failure in the elderly. Current treatment includes restoration of the renal arterial lumen by endovascular stent placement. However, this treatment only affects damage caused by ARAS due to the stenosis and ensuing post-stenotic ischemia. ARAS patients have severe general vascular disease. Atherosclerosis and hypertension can also damage the kidney parenchyma causing renal failure. Medical treatment focuses on the latter. Lipid-lowering drugs (statins) could reduce renal failure progression and could reduce the overall high cardiovascular risk. The additional effect on preserving renal function of stent placement as compared to medical therapy alone is unknown. Therefore, the STAR-study aims to compare the effects of renal artery stent placement together with medication vs. medication alone on renal function in ARAS patients. METHOD: Patients with an ARAS of > or = 50% and renal failure (creatinine (Cr) clearance < 80 mL/min/1.73 m2) are randomly assigned to stent placement with medication or to medication alone. Medication consists of statins, anti-hypertensive drugs and antiplatelet therapy. Patients are followed for 2 yrs with extended follow-up to 5 yrs. The primary outcome of this study is a reduction in Cr clearance > 20% compared to baseline. This trial will include 140 patients.

Angioplasty, Balloon↗