09 Dec 2020
The wandering burr nightmare: coronary perforation during rotablation due to wire fracture
Rotablation is an essential tool for contemporary PCI in managing heavily calcified vessels, but complications can occur. We describe a planned rotablation case in which the burr fractured the rotawire and exited the vessel architecture.
This case was originally published on Twitter by @BElbarouni via #CardioTwitterCase
Clinical presentation
A 70-year-old was referred for coronary angiography in the setting of CCS II-III angina not responsive to medical management.
He was booked for planned PCI to the RCA with rotablation. JR4 7 F guide was used via right femoral access. We crossed the lesion with a Fielded XT-A wire and used a Turnpike Spiral to cross the lesion and exchange with a floppy Rota wire.
Case Management
We proceeded to rotablate the lesion with a 1.5 burr, maintaining rotation speed at 160,000 rpm. Although the burr was slowly advancing through the lesion, it was proving challenging to cross. At one point, the burr cut the wire at the lesion and exited the vessel completely.
At this point, we had two complications, a coronary perforation and wire loss/entrapment. We dealt with the perforation first, we quickly wired next to the burr with a BMW Universal wire. We tried to deliver a balloon over this wire while the burr was still in-situ but failed. We then quickly pulled the burr out, and delivered a 3x20 balloon to tamponade the vessel and block the perforation.
A quick bedside echo showed no evidence of pericardial effusion and the patient continued to be hemodynamically stable. We obtained second access via the left femoral artery and used a second JR4 7F guide as a Ping Pong guide
Figure 2: Ping Pong guides
Through the Ping Pong guide, we advanced another BMW Universal wire across the lesion, exchanged for a Wiggle wire (using the Turnpike Spiral microcatheter), then dilated the lesion with sequential sized balloons using guide extension for support. The blocking balloon was kept inflated throughout this time, only deflating it to allow for equipment delivery. We then delivered and deployed a 3x20 Papyrus covered stent, sealing off the perforation.
Figure 3: final results with complete jailing of entrapped wire with stents
At this point, we still had to address the cut rota-wire, which now was jailed with the covered stent proximally. We did not think retrieval was feasible, so we elected to jail the whole wire with stents into the PDA.
The patient tolerated the procedure well. Only trace effusion was observed on imaging, and he was discharged within 48 hrs. At three months, he was angina free with no residual complications.
Original tweet and Twitter discussion
Just gonna leave this here pic.twitter.com/hukUvqyfay
— basem elbarouni (@BElbarouni) September 27, 2020
Author
2 comments
Great save @ Dr Basem Congratulations! One of the rare complication of RA, I think it’s most commonly seen with use of old or kinked rota wire. Key is to be calm and rapid in achieving balloon tamponade to maintain hemo dynamic stability.
Can you, retrospectively, identify any features that explain why the burr cut the wire? Looking back, wd u have done anything differently? Why not a 1.5mm burr from the outset? Thank you.