Remove the shaft technique: tips and tricks
A problem-solving step by step tutorial
When a rota burr stalls in a calcified artery, quick thinking and the right technique are critical. Discover a proven method to recover the burr safely and avoid surgery.
Frequency of the problem:
Expert level:
Summary
A stalled rota burr is an entrapped burr inside a heavily calcified vessel, and it is a situation you really do not want to be in.
However, due to the increasing numbers of heavily calcified vessels treated, it is inevitable that you will face such a complication sometime in your interventional career, regardless of the level of your expertise.
The problem
Therefore, you must be prepared, design a plan in your mind and have the necessary tools on your shelf. If you stay calm and follow the steps carefully, in most cases, the burr will come out successfully.
Do not surrender easily, and keep in mind that surgery is not a good alternative, as these patients have poor revascularisation targets and, most likely, the surgeon will bypass the artery, leaving part of the shaft and burr behind.
Principal idea
The first manoeuvre which automatically comes in your mind is to pull the shaft. This is rarely successful, especially if you are stuck in the middle of a long, heavily calcified segment.
To be able to release the burr, you need to create some space inside the vessel, but, most importantly, inside the guiding catheter, especially if you work with a 6F. Balloons and extension catheters do not fit in a 6F guiding catheter next or over a rota shaft.
We are describing a technique to retract the plastic cover of the rota shaft in order to load an extension catheter over the remaining metallic shaft to reach the burr and successfully remove it.
Material needed
- A pair of sterile scissors
- A 6F extension catheter
Step-by-step method
Step 1
Retract the rotawire till the beginning of the spring tip reaches the burr. Remember, the radiopaque part of the rotawire is thicker than the rest of the wire and does not fit inside the burr. This gives extra support when you pull the whole system. Do not pull hard yet (video 1).
Step 2
Disassemble rota system. Take a pair of sterile scissors and cut the shaft and the wire at the distal, near the advancer (video 2).
Step 3
The guide extension catheter cannot advance over the external plastic sheath, therefore you need to remove the external plastic rota sheath first (videos 3, 4).
Step 4
Feed guide extension catheter over the remaining metallic shaft of rota burr.
Advance guide extension catheter as deeply as possible against the burr, and pull the whole system (video 5).
Key points
- The burr does not always pop out at once. Sometimes, you notice a gradual removal and you must apply force several times.
- During the maneuvers, give vasodilators to the patient if hemodynamics permit.
- Have workhorse wire ready to use. After the removal of the stalled burr, you loose access of the lesion and the distal vessel.
A word from the reviewer - Nicolas Amabile
Rotablator burr blockage is a rare but feared complication in a cathlab. Factors contributing to this complication include the treatment of tortuous and/or angulated and/or tandem lesions, the use of atherectomy in under-deployed stents, insufficient burr rotational speed, and excessive force applied to the burr.
The consequences of burr blockages depend mainly on the interruption of blood flow in the target vessel, which depends on the diameter of the device, the residual internal luminal area, and the presence of associated intimal dissection.
Percutaneous burr unblocking techniques can be classified into three categories:
- strong, controlled traction on both catheter shaft and rotawire, with advancement of the guiding catheter as close as possible to the burr (which remains an effective option in a consequent number of cases);
- Ping-pong strategies derived technique, with the use of a second guiding catheter, placement of a second wire parallel to the blocked burr (in an intraluminal or subintimal position), and the use of a balloon to dislodge the material;
- Rotablator catheter shaft cut and burr dislodgment using a guiding catheter extension (GCE).
This latter strategy is the most radical of all, as it involves destroying the material and temporarily losing the guide's position in the arterial lumen. However, this technique, which is very well described by the authors, is particularly effective and may be the last resort before requiring surgical extraction. To perform it, it is crucial to use surgical scissors or, better still, dedicated surgical cutting forceps. This accessory should ideally be available and immediately accessible in any center performing rotablator procedures.
Finally, the operator must bear in mind that preventing burr blockage is an important part of the procedure, and will require careful analysis of the lesion prior to the procedure (in order to identify the risk factors mentioned above), the use of large bore catheters (7 Fr) in order to be able to use large burrs or to facilitate the use of a large GCE, and a rigorous rotablator technique combining phases of repeated ‘pecking motion’ (with return to the starting position after passing through the lesion without stopping the rotation of the burr) and phases of ‘polishing’, all at high speed (> 150 kRPM) and monitoring for any deceleration (> 5000 RPM) of the device during atherectomy.
References
- Dmitriy S. Sulimov et al. Step-by-step algorithm for the management of an entrapped rotablation burr - Stuck rotablator: the nightmare of rotational atherectomy EuroIntervention. 2013 Jun 22;9(2):251-8
- Frederic De Vroey et al. How should I treat an entrapped rotational atherectomy burr?
- PCR-EAPCI Textbook: Volume II Intervention I - Part III Chapter 24: The prevention and management of complications during percutaneous coronary intervention
- Case study by Olivier Muller: Entrapment of a rotablator in a freshly implanted stent surgically extracted
- Case study by Benjamin Faurie: Case study: my most memorable radial case - a stuck Rota burr
Disclosures
The authors declare no conflicts of interest to disclose.
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