04 Apr 2019

Other coronary interventions Complications

Case study: my most memorable radial case - a stuck Rota burr

Complications Rotablator

Learn how CTO’s skills can help in everyday practice in this clinical case by B. Faurie and M. Abdellaoui from the Cardiovascular Institute of GHM, Grenoble on an 82-year-old male patient with chronic anaemia.

Authors

Mohamed Abdellaoui

Benjamin Faurie

@FaurieBenjamin1

Interventional cardiologist / Cardiologist

INFIRMERIE PROTESTANTE - Lyon, France

Part 1 - Presentation & procedure

By M. Abdellaoui , B. Faurie

Clinical presentation

82-year-old men, DM II, DL, BMI: 32, COPD, chronic anaemia
ACS without ST elevation with acute renal and pulmonary failure
Troponins (870 pg/ml); Hb 112g/l, Creat 87 then 145 umol/l

After 2 days medical stabilisation: Coro angiogram by right radial approach

Angiograms

Proximal LCx stenosis

RCA angiogram showing proximal and distal calcified lesion

PCI of LCx done with DES

Procedure

2 weeks after:

Same right radial approach: radial and brachial tortuosities
6Fr AL 1 guiding
1.5 mm Rota burr

Crossing failure of Rotawire, crossing failure of Sion Blue guidewire, crossing success of Fielder FC, crossing success of microcatheter, Rotawire to distal RCA

Burr 1.5 mm: Stalled and totally blocked in the lesion → chest pain and inferior ST elevation

Part 2 - Complication management

What would you do?

2nd radial access to canulate RCA with another AL 1 after decanulation of the first guiding

Knucle Wire Technique with Fielder XT (sub intimal) after attempt to cross a balloon along the rota burr (failure)

Guidewire in sub intima and re entry

1.25 mm balloon inflation

2.0 balloon inflation

3.0 balloon inflation

Angio assessment after multiple balloon inflation in sub intima

Burr removed with deep intubation

Result after burr removing

New burr 1.25 mm

Angio assessment after rotablation

Final result after 2 stents implanted

Part 3 - Reflection

Key messages

How to prevent a stuck rota burr?

Rule n°1: Release the tension!
- Push-pull catheter / Rota
- Translation control knob
- Dynaglide
Rule n°2: low speed rotablation - Barbeau’s technique
- 120 - 140 000 Rpm
- Very slow burr advancement
- Listening the sound of the burr
- Resulting in:
  - No more / No-reflow
  - No more burr blockage
  - No need for pacing lead

How to manage a stuck rota burr?

Have an algorythm in the head