Stuck Between a Rock and a Hard Place: Management of an Entrapped Rotablator Burr

The limited antegrade subintimal tracking technique to retrieve a trapped rotablator burr: a case report

Background

Burr entrapment is a rare, but potentially serious complication of rotablation. This report describes the percutaneous options available for Rota burr retrieval.

Case summary

A 62-year-old Caucasian man with stable angina presented for percutaneous coronary intervention. Attempted rotablation with a 1.75 mm burr resulted in Rota burr entrapment, in the heavily calcified proximal right coronary artery. A chronic total occlusion angioplasty technique (limited antegrade subintimal tracking) was successfully used to remove the trapped Rota burr, by enabling subintimal dilatation to externally crush plaque and dislodge the burr. The angioplasty procedure was then completed using the wire that had a short subintimal passage, before re-entering the true lumen.

Discussion

The mechanism for Rota burr entrapment, in this case, was initiating rotablation on the heavily calcified lesion and not more proximal to allow a pecking motion. The learning points are (i) to start the rotablator several millimetres proximal to the actual lesion, and (ii) if unable to wire alongside a trapped Rota burr in the true lumen, then subintimal crossing and balloon dilatation in the subintimal space may work to dislodge the burr.

Slender Bi-Radial Ping-Pong Technique for Complete Revascularisation of Concomitant CTO and Non-LM Bifurcation Lesions: A Report of Two Cases

The "ping-pong" technique entails the use of two different guide catheters to alternately engage the same coronary artery during percutaneous coronary intervention (PCI). Bi-arterial vascular access for dual injection is the standard of care in contemporary chronic total occlusion (CTO) PCI. Two-stent bifurcation PCI strategies require a minimum of 6 French (F) guide catheter. In this report, we describe two cases where dual access initially made for CTO PCI was leveraged for subsequent bifurcation PCI in the same setting, by means of two 5F Judkin's Left (JL) guides in a transradial "slender" double-guiding catheter "ping-pong" strategy. In both cases, two 5F JL guides were initially navigated via bi-radial access for antegrade and retrograde injection from left anterior descending artery (LAD) and right coronary artery (RCA) respectively, to facilitate PCI to CTO of LAD. After successful crossing of the LAD CTO lesions, we took advantage of the two 5F JL guides already present via this dual access created for CTO PCI, to adopt the novel use of the "ping-pong" guide technique in order to perform bifurcation PCI by two-stent strategy. In the first case, PCI of the left circumflex (LCx)/obtuse marginal (OM) bifurcation was performed by the DK-Culotte technique with two JL 5F guides used to alternately engage the left main (LM) coronary artery, with wiring and passage of equipment to the LCx and OM done via separate "ping-pong" guides engaging the LM. In the second case, LAD/Diagonal bifurcation PCI was performed by T and protrusion (TAP) technique in a similar slender fashion via "ping-pong" guides. This approach has limited indications. As described in our case report, the CTO lesion was relatively less complex, the LM was not diseased and importantly, narrow radial artery diameters of the patients precluded the use of larger 6F guide transradially. Advantages of this ping-pong technique in bifurcation PCI include the avoidance of wire wrap, accommodation and easy delivery of multiple hardware, and the non-necessity of changing multiple guides, thus reducing radial artery spasm, particularity among those with narrower radial artery diameters.

Get Out of Jail: Managing an Entrapped Balloon Using Subintimal Plaque Modification

Balloon entrapment is a potentially fatal complication of percutaneous coronary intervention. This report describes the use of subintimal plaque modification for the management of entrapped balloons. This technique, commonly done during chronic total occlusion angioplasty, was used successfully to retrieve the balloon. (Level of Difficulty: Advanced.).