02 Apr 2019

Other coronary interventions Complications Interventional CV surgery

Case study: entrapment of a rotablator in a freshly implanted stent surgically extracted

Complications Rotablator

Consult this clinical case of a 75-year-old male patient by O. Muller on Rotablator entrapment, if you want to learn how to manage a rotablation atherectomy complication via surgery.

Author

Olivier Muller

Interventional cardiologist / Cardiologist

Lausanne, Switzerland

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Part 1 - Presentation & procedure

By O. Muller

Clinical presentation

75-year-old male admitted for chest pain
Laboratory: HS-troponin : 21 ng/l (T0) à 47 ng/l (T2) à 56ng/l (T6)
EKG: ST-segment depression in V3-V6 and avL

History

CABG in 2000
- Obtuse marginal artery (venous graft)
- Left circumflex artery (CX) (venous graft)
- Right coronary artery (RCA) (venous graft)
- Left Anterior Descending artery (LAD) (arterial graft)
Myocardial infarction in 2003
- Venous graft to RCA: occluded
- Occlusion of proximal RCA treated with stent implantation (BMS)

Angiogram

LIMA to LAD: patent
All venous grafts: occluded
RCA:
- 30% restenosis of the proximal RCA
- 90% stenosis of the mid RCA
- 90% stenosis of the distal RCA
- 70% stenosis of the posterior lateral artery
Diagnosis: ACS due to RCA stenoses (culprit)
Decision: PCI of mid and distal RCA

PCI

MID RCA

Non-compliant balloons (3.5 X 10 mm balloon OPN NC high pressure, SIS medical): FAILED
Scoring balloons (AngioSculpt PTCA, Biotronik): FAILED
Cutting balloons (Flextome, Boston Scientific): FAILED
No stenting

Distal RCA

Pre-dilatation: 2.5 x 15mm and 3 x 15mm balloons (BEO NC low profile high-pressure PTCA balloons, SIS medical)
Stenting: 28 x 3mm EES (Xience, Abbott Vascular)

2 Day follow-up

Chest pain recurrence
Elevated HS-troponins
Stent thrombosis? Dissection?
Coronary angiogram in emergency

Angiogram in emergency

Good result of the PCI
No stent thrombosis or dissection
2 remaining lesions :
- Mid RCA
- Postero-lateral artery

Decision was made to perform a rotablation in the mid RCA.

Femoral access & Pacemaker
Rotational Atherectomy System (Boston Scientific): 1.25mm Burr; 16’000 rpm; Guide Rotawire Extra Support (Boston Scientific)

Rotablation (1st round)

Rotablation (2nd round)

The burr remains stuck in the distal stent.

Part 2 - Complication management

Twisting method, balloons

Deep intubation

Angiogram of the RCA

Time procedure: > 100 minutes, TIMI 0 to mid RCA → decision to surgery

Surgery

Conclusion

We should have proceed to rotational atherectomy before implanting the distal stent
We probably did not treat the culprit lesion

For more information please consult the EuroIntervention article by Dmitriy S. Sulimov et al. on Stuck rotablator: the nightmare of rotational atherectomy

An additional risk factor for burr entrapment - at least in our experience - may be rotablation of a freshly implanted underexpanded stent.

Part 3 - Reflection

Key messages

We should have proceed to rotational atherectomy before implanting the distal stent
We probably did not treat the culprit lesion