A stuck Rota burr in a "flintstone" coronary artery

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @jorgeachv

Clinical presentation

• 67-year-old man, former smoker, HTN, DMII
• ACS without ST elevation, troponin (106-125 pg/ml), creatinine 1.04 mg/dl
• Echocardiogram with mild mid- and apical hypokinesis at the anterior wall. Ejection fraction 60 %.
• View baseline angiogram on Video 1.

Diagnosis

After stabilization, patient was diagnosed with severe and calcified LM and MVD disease, poor distal bed for bypass. Heart team decision was to perform a PCI with atherectomy.

Burr entrapment (BE) consists of its embedment through a severe stenosis, preventing both further advancement or retrieval. Several bail-out techniques have emerged to deal with this complication. One of these techniques is to use a second wire and to inflate a balloon (balloon-trapping technique).

Case description

We present the case of a 67-year-old male with LM and MVD who underwent two complex coronary interventions with long runs of atherectomy.

During mid-distal rotablation with 1.25 mm burr, a stuck coronary burr due to Kokeshi phenomenon was observed. ACT was confirmed above 250 seconds. A guide extension catheter (GEC) was passed over the shaft of the entrapped burr, a second guidewire over a microcatheter was able to pass through the lesion and the stuck burr, and balloon escalations were used to successfully release the burr (Videos 2 and 3).

A balloon-trapping technique was performed successfully, and this maneuver unblocked the entrapped burr.

Intravascular imaging with IVUS was performed to rule out iatrogenic complications in the proximal segments of the artery and left main (Figure 1).

Staged procedure to perform double-kissing culotte in the left main, provisional to intermediate ramus, balloon angioplasty in mid-distal LAD, and diagonal branch, was successfully performed, guided by IVUS (Figure 2 and Video 4).

A 3-month follow-up was scheduled to determine the need for future intervention on the left anterior descending artery.

Videos:

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Figures:

Final remarks

After successful retrieval of an entrapped burr with the help of a second wire and GEC, potential iatrogenic complications can be diagnosed or solved in an efficient and safety way. Intravascular imaging must be performed before the retrieval of distal wires.