How to solve rotational atherectomy burr entrapment with a guide extension catheter in 4 steps

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Summary

Rotational atherectomy (RA) remains the most used device for calcified coronary lesion preparation, and its technique has evolved considerably in the last decade. A more conservative approach, based on plaque modification to facilitate balloon angioplasty and stenting, has significantly decreased complication rates. Nonetheless, complications may still occur, and burr entrapment (BE) is a particularly serious one that may lead to abrupt vessel closure and need for surgical removal of the device. Position of the diamond crystals in the distal half of the RA burr may predispose to BE, since it can only ablate in a forward movement. BE is best prevented by meticulous application of proper rotablation technique. Operators need, however, to learn the steps involved in resolving this complication, should it occur. In this My toolkit session, we describe (with video illustration) the step-by-step technique for resolution of an entrapped RA burr using a guide-catheter extension.

The problem

BE consists of its embedment through a severe stenosis, preventing both further advancement or retrieval. Its incidence ranges from 0.5 to 1 %. Careful case selection to avoid excessive tortuosity and conservative technique with gentle pecking motion, short ablation runs (< 20 seconds), avoidance of decelerations > 5000 rpm, and maximum burr-to-artery ratio of 0.4-0.6 are essential to prevent it. Several bail-out techniques have emerged to deal with this complication. If manual pullback or positioning of a second guidewire for balloon dilatation next to the entrapped burr are not successful, cautious deep intubation with a Guide Extension Catheter (GEC), loaded in a partially disassembled RA burr, may be safely applied.

Principal idea

Deep guide catheter intubation has been used to increase support and facilitate entrapped burr removal, prior to the advent of GEC. However, coronary deep intubation with guiding catheters is not always possible and can lead to severe catheter-induced dissection. By loading the GEC onto the RA drive shaft, one can safely deliver it to the lesion site in order to increase the support of the system and allow burr retrieval from the coronary.

Material needed

1. 7Fr Guide Extension Catheter (6Fr GEC will fit a 1.25 Burr)
2. Sharp surgical scissors.

Method step-by-step

1. Cut the RA drive shaft with sharp surgical scissors as close as possible to the black rubber connection of the advancer
2. Pull out the plastic drive shaft sheath and expose completely the drive shaft of the burr
3. Load the GEC onto the drive shaft
4. Advance the GEC against the burr in the coronary and pull back the whole system

Points of specific attention

After successful retrieval of an entrapped burr with GEC assistance, one should pay specific attention to iatrogenic complications. Therefore, operator should be prepared to rapidly reaccess coronary artery with an atraumatic guidewire or get second arterial access if coronary perforation is diagnosed. Once hemodynamic stability of the patient is confirmed, a careful analysis of the potential reasons for BE should be performed in order to prevent it if RA is to be attempted again.

Other resource

• PCR Edu Online- Undilatable coronary artery lesions - Chapter 5, Complications: Burr entrapment