Abstract
We report the occurrence of catheter tip erosion during use of a Rotablator, a rare but serious complication. A heavily calcified lesion of the right coronary artery ostium required use of a Rotablator, and the need for strong push led to the choice of an Amplatz Left guiding catheter. The traction of the catheter toward the ostium and the subsequent angle generated led to friction of the burr against the catheter and the erosion of its tip. If judged essential to get strong support, the Amplatz catheter should be used with caution in this setting.
Highlights
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Catheter tip erosion is an exceptional but serious complication that may occur during percutaneous coronary intervention with Rotablator use.
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Calcified lesions of the right coronary artery ostium are favorable location for this kind of complication.
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If judged essential to get strong support, the use of Amplatz Left guiding catheter in this setting should be use with caution.
We report the case of an 80-year-old woman having recently undergone non-ST elevation myocardial infarction revealing diffusely hypokinetic dilated cardiomyopathy with LVEF of 30%. Coronary angiogram showed a multivessel coronary artery disease with heavily calcified atherosclerotic lesions. We found a stenotic proximal left anterior descending (LAD) coronary artery and a suboccluded proximal left circumflex artery branching out into a large obtuse marginal artery ( video A & B ). However, the most severe lesion was the critically stenotic ostium of a severely calcified right coronary artery (RCA) followed by a calcified stenosis of its medium segment ( video C ).
Recurrent chest pains uncontrolled by medical therapy limited by hypotension oriented our treatment strategy towards revascularization. After a discussion between members of the local Heart Team, impaired LVEF, underlying dementia and reduced mobility with high risk of postoperative severe morbidity and mortality tipped the decision in favor of percutaneous revascularization using rotational atherectomy. Attempting a first-hand approach of the left anterior descending artery would have led to severe per-procedural myocardial hypoperfusion and risk of cardiogenic shock or cardiac arrest. We therefore decided to minimize procedural risk by beginning with right coronary repermeabilization.
The procedure was staged 3 months later. We used a 7-French right femoral approach and an Amplatz left 1 (AL1, Cordis vista brite tip®) guiding catheter was advanced into the ascending aorta and placed immediately facing the stenotic ostium of the RCA. Angiography immediately revealed that the lesion had progressed towards sub-total occlusion of the RCA ostium ( video D ) and we therefore decided to add a left femoral 6F introducer and 6F Judkins left diagnostic catheter for controlateral injection of the left coronary artery to visualize the RCA using the collateral flow from the LAD.
A medium support floppy-tipped high torque 0.014 in.-tip polymeric guide wire (Whisper, Abbot) was descended through the AL1 into the RCA with relative ease after the narrow opening of the artery had been crossed and used to guide a parallel ROTA-wire (Boston scientific), the end of which was positioned in the left posterior descending coronary and the Whisper guide wire was removed ( video E ). A 1.5 mm Burr was descended in Dinaglide mode and placed approximately 10 mm from the tip of the AL1 guiding catheter ( video F ).
We activated the burr inside the guiding catheter just before the emergence of the stenotic right coronary ostium at a speed of 170 to 180,000 rotations per minute. We encountered strong resistance when advancing the burr across the RCA ostium threshold, which manifested by slowing of the motor’s rotational speed and an unusually high-pitched sound coming from the Rotablator console. A total of more than ten forward-movements were necessary before crossing the obstacle and reaching the second RCA segment. The strong resistance seemed linked to the extremely calcified nature of that segment.
However, success was quickly followed by severe bradycardia with an almost flatline EKG and extremely slow ventricular escape rhythm due to a very probable severe sinus dysfunction requiring cardio-pulmonary resuscitation maneuvers and injection of epinephrine permitting recuperation of an atrial fibrillation rhythm, restoration of a stable hemodynamic state and normal consciousness after two to three minutes without necessity of intubation or further vasopressors or inotropic drugs.
The initial injection during cardiac arrest to angiographically identify the cause showed total RCA ostial occlusion ( video G ). Then, the resuscitation maneuvers having caused the extubation of the guiding catheter and extrusion of the guidewire from the RCA, and, fearing a thrombus at the tip of the catheter that may have caused the afore-mentioned occlusion, we retracted the AL1 catheter and identified a substantial loss of substance at the tip of the AL1 guiding catheter as shown in Fig. 1 .
