Figure 22.1
The right coronary artery (RCA) on LAO view shows a calcified and tortuous vessel with a tight 90% midsegment stenosis
Using a 6F sheath via right femoral arterial access, percutaneous coronary intervention to the proximal LAD was successful. The RCA was then engaged using AL1 6F catheter and wired using a Sion wire (Asahi Intecc Co. Ltd, Japan). The severely stenosed and calcified mid-RCA lesion was not adequately predilated despite the use of a 2.5-mm semi-compliant and 3.5-mm and 4.0-mm non-compliant balloons, respectively (Figs. 22.2 and 22.3). The decision was then made to perform adjunctive rotational atherectomy.
Figure 22.2
Multiple attempts were made to predilate the tight calcified lesion. Note the persistence of the tight “waist” in the middle of the inflated balloon
Figure 22.3
The mid-RCA lesion is not adequately dilated even after multiple inflations
An intravenous pacing wire was inserted prior to the setup of the Rotablator system (Boston Scientific; USA). Using an 8F guiding catheter, a Finecross microcatheter (Terumo, Japan) was used to exchange the Sion wire for a floppy Rotawire (Boston Scientific; USA) which was easily introduced into the distal RCA. Rotablation for the heavily calcified RCA was performed using a 1.5-mm Rotablator burr initially at 170,00 rpm and followed by a 2.15-mm burr. Rotational atherectomy of the 2.15-mm burr also at 170,000 rpm was performed, but after two runs, it was suddenly trapped at the mid-RCA (Figs. 22.4 and 22.5, Videos 22.1 and 22.2).
Figure 22.4
The 2.15-mm burr gets trapped during the rotablation procedure
Figure 22.5
The burr is stuck in between the tight calcified plaque of the mid-RCA (Supplementary material available Videos 22.1 and 22.2)
The team called for urgent surgical backup to be on standby while percutaneous retrieval of the trapped burr was attempted. The burr could not be removed easily by simple pulling nor with manual traction with off-on low-speed rotation in Dynaglide mode. A second guidewire was then inserted in an attempt to place a buddy wire beside the trapped burr but was also unsuccessful.
In our next method, we proceeded with the following sequence of steps: (1) we cut off the drive shaft and sheath of the Rotablator catheter; (2) we then inserted a 5 Fr 120-cm guiding catheter (Heartrail ST01; Terumo, Japan) through the remaining Rotablator system and up to the end of the burr; (3) then we pushed the catheter tip to the lesion around the burr accompanied by simultaneous pulling back of the Rotablator; and (4) with this push-and-pull technique, we successfully removed the trapped burr (Figs. 22.6 and 22.7, Videos 22.3 and 22.4).
Figure 22.6
Applying the child in mother technique. After cutting off the Rotablator shaft, a 5F Heartrail catheter was inserted up to the end of the burr. Simultaneous pullback was applied on the Rotablator, while countertraction was applied on the catheter
Figure 22.7
The Rotablator burr was successfully retrieved with continuous further manual traction (Supplementary material available Videos 22.3 and 22.4)
Coronary angiogram after the retrieval of the burr showed an adequately prepared mid-RCA lesion with no dissection. We then rewired the RCA using a Fielder guidewire and were able to predilate successfully using a 3.5-mm scoring balloon (AngioSculpt; Biotronik, Germany) and a 4.0-mm non-compliant balloon. We then proceeded to successfully deploy two overlapping 4.0-mm drug-eluting stents in the mid- and proximal RCA, respectively, followed by postdilatation using a 4.0-mm non-compliant balloon. The final angiographic result was favorable with good flow and no residual stenosis noted (Figs. 22.8 and 22.9).
Figure 22.8
A drug-eluting stent is deployed in the mid-RCA area after retrieval of the trapped burr and lesion preparation
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