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Burr Entrapment – Case 3

Clinical Presentation

  • 63-year-old male who presented with a NSTEMI. Underwent cardiac catheterization showing LM equivalent 3-Vessel CAD and was referred for surgical revascularization. However, he was deemed to high risk for surgery, and referred for PCI of the RCA.

Past Medical History

  • HTN, CAD s/p Multiple PCI’s, s/p ICD, AFIB, ESRD on iHD, HTN, PAD s/p BKA
  • LVEF 20%

Clinical Variables

  • Prior Cardiac Catheterization: Proximal LAD 80-90% stenosis, mid LAD 60-70% stenosis, distal LAD 70-80% stenosis, proximal LCx 70-80% stenosis, LPL CTO ISR, proximal RI CTO, proximal RCA 70-80% stenosis, mid RCA 80-90% stenosis, distal RCA subtotal stenosis.

Medications

  • Home Medications: Aspirin, Ticagrelor, Atorvastatin, Metoprolol Succinate, Lisinopril, Pantoprazole, Sevelamer Carbonate
  • Adjunct Pharmacotherapy: Ticagrelor, Heparin IV

Pre-procedure EKG

Angiograms

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Left coronary artery angiography
  • 70-80% in-stent restenosis lesions in the proximal, mid and distal left anterior descending (LAD) coronary artery.
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Left coronary artery angiography

  • 70-80% in-stent restenosis lesions in the proximal, mid and distal left anterior descending (LAD) coronary artery.
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Impella was placed followed by right coronary artery (RCA) angiography

  • 70-80% proximal, 90-95% mid and 80-90% distal stenoses in the calcified tortuous RCA.
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RCA wired with a Fielder wire which was exchanged for a Rota-Extra Support wire using a FineCross microcatheter. A 1.25mm burr was advanced, and it became trapped in the RCA. Subsequently, the RCA was re-wired with a Fielder wire.

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An Emerge 2.0/20mm balloon was advanced over the Fielder wire to the location of the trapped burr, and inflated.

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Rota shaft was cut outside the body, and the teflon sheath removed exposing the drive shaft. 7 Fr Guidezilla catheter was threaded over the drive shaft and positioned proximal to the entrapped burr. Guide catheter was disengaged and traction applied to the system to retrieve the burr. However, this led to fracturing of the rota-wire, with 25cm freely hanging within the aorta.

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Unable to retrieve the burr and rota-wire. Decision was made to exclude the burr with a stent and anchor the wire to prevent it from embolizing. Angiography shows distal lesion being pre-dilated.

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Pre-dilatation of the mid RCA lesion with a Mini Trek 2.0/8mm balloon.

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Pre-dilatation of the mid RCA lesion with a Mini Trek 2.0/8mm balloon.

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Pre-dilatation of the mid RCA lesion with a NC Emerge 3.0/12mm balloon.

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Angiography of the RCA after lesion pre-dilatation.

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Deployment of a Synergy 3.5/16mm stent in the proximal RCA to exclude the entrapped burr and anchor the rota-wire.

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Angiography after placement of a stent in the tortuous segment of the proximal RCA to exclude the entrapped burr.

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Post-dilatation of the stent in the proximal RCA with a Trek NC 3.0/12mm balloon.

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Final angiography showing exclusion of the entrapped burr and preserved flow in the RCA.

Post-procedure EKG

Case Overview

  • Underwent Impella guided intervention of the RCA.
  • During the procedure, the rota burr stalled and became entrapped in the tortuous segment of the proximal RCA.
  • While using multiple techniques to retrieve the burr, the rota-wire fractured and migrated outside the guide catheter/Guidezilla extension catheter with ~25cm of the wire freely hanging within the lumen of the aorta.
  • Decision was made to exclude the entrapped burr with a stent.
  • This was followed by placement of an additional stent in the mid RCA, and unsuccessful intervention of the distal RCA.
  • Impella was removed at the end of the procedure.
  • Troponin-I peaked at 2.54 ng/mL and CK-MB peaked at 2.2 ng/mL.
  • Patient was discharged home 4 days later without further sequelae.

Learning Objectives

  • What is the likely explanation or reason why the complication occurred?
    • Two mechanisms for burr entrapment include:
      • ‘Kokesi’ phenomenon: When performing rotablation at high RPM, frictional heat is generated and it may enlarge the space between plaque. In addition, the coefficient of friction when the burr is in motion is less than that at rest, which may facilitate the burr to pass the calcified lesion easily without debulking a significant amount of calcified tissue. Once the burr traverses the lesion, and the plaque cools the between the plaque is again reduced, and the ledge of calcium proximal to the burr prevents the withdrawal of the burr, which is known as ‘Kokesi’ phenomenon, a name given after a Japanese doll.
      • Burr can become entrapped within a severely calcified ,long and/or angulated lesion when the burr is advanced aggressively. When a large burr is pushed forcefully against this kind of lesion without an appropriate pecking motion, significant decelerations occur and this produces more debris which increases the risk for slow flow/no-reflow and burr entrapment.
  • How could the complication have been prevented?
    • The burr is oval shaped and coated with diamonds at its distal end, allowing for antegrade ablation. However, the proximal end is smooth and not coated with diamonds, prohibiting retrograde ablation. If a burr is advanced beyond a tight calcified lesion or embedded in a long, angulated and heavily calcified lesion, it can be entrapped. Burr entrapment can often be avoided using the following techniques/strategies:
      • Use a gentle pecking motion with shorter runs of ablation (<20s).
        • Do not exert excessive forward force during burr advancement. If the burr is advanced aggressively, it causes decelerations and can become embedded in the calcified lesion.
        • The risk for burr entrapment is greater when the lesion is long and heavily calcified, and the vessel is highly angulated.
      • When advancing the burr, avoid decelerations >5000 RPM because this results in more debris production and increases risk for slow flow/no-reflow and burr entrapment.
      • When using a smaller burr, avoid using a higher speed of rotation (>180k RPM) to prevent ‘Kokesi’ phenomenon.; optimal speed is around 150k RPM.
      • If the vessel or lesion is highly tortuous/angulated, a stiffer wire can be used to straighten the vessel or lesion to lessen the resistance and reduce wire bias.
    • Avoid performing rotational or orbital atherectomy in vessels which are highly tortuous, especially if severe wire bias is present. Consider using Intravascular Lithotripsy (IVL) (off label use in the USA) for plaque modification and treatment of calcified CAD.
  • Is there an alternate strategy that could have been used to manage the complication?
    • Several bailout techniques can be used to retrieve a trapped burr, but prior to proceeding forward.
      • Assure patient is adequately anticoagulated (ACT >300) before attempting percutaneous retrieval.
      • Administer intracoronary vasodilators to facilitate antegrade coronary flow and relieve possible spasm.
    • Potential strategies for retrieval of an entrapped burr include the following:
      • 1st: Manual traction of the rotablator system by pulling the burr, guidewire and/or guide catheter as a unit. This can be performed on or off Dynaglide. The vessel is at risk for perforation, dissection, and abrupt vessel closure  (AVC). In addition, the burr shaft can fracture. If you are pulling the burr and guidewire as unit (and not the guide catheter), remember to disengage the guide catheter to prevent injury to the coronary artery from it deep seating during traction.
      • 2nd: Pass a second wire (hydrophilic-coated guidewire) beyond the trapped burr, followed by balloon dilatation around the burr. This may alter the architecture of the calcified lesion and possibly free the trapped burr. However, a 4.3 Fr rotablation drive shaft sheath may prohibit introduction of a balloon catheter into the guide catheter (consider this possibility if using a 6 or 7 Fr guide catheter). To overcome this, use a two-catheter strategy (Ping-Pong technique) where a second vascular access is obtained and equipment necessary for burr retrival is introduced through. If a single guide catheter strategy is preferred, there are two options. On approach includes cutting the rota system near the advancer, and remove the sheath to expose the driveshaft surrounding the rota-wire. This approach makes room for introduction of a second guidewire and balloon. This approach is useful when using a 6 Fr guide catheter. Alternatively, you can upsize the access sheath and guide catheter to a 8 Fr.
      • 3rd: Mother-child catheter technique can be used to wedge the burr and facilitate retrieval. The system is cut near the advancer, and the Teflon sheath is removed exposing the driveshaft which surrounds the rota-wire. A child catheter (monorail 5 Fr Guideliner or 5 Fr Guidezilla) is inserted over the exposed drive shaft and positioned as close as possible to the entrapped burr. With simultaneous traction on the burr shaft and counter-traction on the child catheter, the catheter tip wedges between the burr and the surrounding plaque, exerting a larger and direct pulling force to retrieve the burr.
      • 4th: Exclusion with a stent (As was done in this case).
      • 5th: Emergent surgical retrieval should always be the last option for removing an entrapped burr, but is often required.
  • What are the important learning points?
    • Interventional cardiologists who uses rotablation, must be familiar with complications associated with its use and their management, particularly burr entrapment which is a rare but serious complication (incidence is ~0.4%, and occurs more frequently when rotablation is used off-label).
    • Prior to retracting the burr using the various techniques above, consider disengaging the guide catheter and holding it fixed with one hand (usually the left) to prevent injury to the coronary artery from it deep seating while pulling the equipment with the opposite hand (usually the right).
Educational Content

ROTATIONAL ATHERECTOMY COMPLICATIONS

  • Common complications associated with rotational atherectomy are:32
    • Slow flow / No-reflow
    • Coronary Dissection
    • Coronary Perforation
    • Burr entrapment

Slow flow / No-reflow

  • It is most feared and preventable operator-dependent complication of Rotational Atherectomy (RA)
  • Incidence- 2.6% in the drug-eluting stent era33
  • Omens of slow-flow / no-reflow include sudden decelerations and visual, tactile or auditory clues of high resistance to burr advancement
  • Be mindful of incident chest pain, ST-segment elevations, hemodynamic instability, and bradyarrhythmia while burring which could signal no-reflow phenomenon
  • Prevention
    • Optimal antiplatelet and anticoagulant therapy
    • Continuous flush cocktail
    • Smaller burr sizes (Max burr to artery ratio 0.4-0.6)
    • Lower speeds (140-150K rpm)
    • Short ablation runs of 15-20 seconds
    • Pause between runs
  • Treatment
    • Correction of hypotension with fluids, vasopressors, and pacing as required
    • Administration of intracoronary vasodilators, such as adenosine, nitrates, nitroprusside, nicardipine, and verapamil administered distally in the vessel
    • If hemodynamically unstable, insertion of an intraaortic balloon pump to augment coronary perfusion pressure

Coronary Dissection

  • Dissections during RA are described and graded in standard fashion using the NHLBI classification system (A-F)
  • Incidence: 1.7%- 5.9% in the drug-eluting stent era 34
  • Like slow-flow / no-reflow, dissection can present with signs and symptoms of acute myocardial ischemia including chest pain, ST-segment elevations, and hemodynamic or electrical instability
  • Prevention:
    • Avoid rotablation in excessively tortuous vessels
    • Avoid excessive angulation while burring
    • Smaller burr sizes
  • Treatment:
    • Stop further ablation
    • Maintain wire position
    • Expeditious completion of PCI via balloon angioplasty and stenting if feasible

Coronary Perforation

  • Perforation represents a more severe variant of dissection in which disruption extends through the full thickness of the arterial wall.
  • Incidence: 0-2% in the drug-eluting stent era34
  • Coronary perforations during RA are described and graded in standard fashion using the Elis classification scheme (I-III)
  • Although RA is considered a risk factor for perforation,1 the majority of type III perforations result from balloon angioplasty 6
  • Risk factors: lesion-specific predictors of perforation include eccentricity, tortuosity, length >10 mm, and location in the right coronary artery or left circumflex artery
  • Prevention:
    • Correct burr sizing
    • Avoid aggressive burring
    • Avoid excessive angulation
    • Lower speeds
  • Treatment:
    • Stop further ablation
    • Maintain wire position
    • Discontinuation of anticoagulation
    • Prolonged balloon inflation (10-15 min) proximal or at site of injury. If still bleeding, repeat prolonged balloon inflation
    • If extravasation persists, seal the site with either occlusive coils [perforation site distal main vessel] or by implantation of polytetrafluoroethylene (PFTE) covered stent [perforation siteproximal main vessel, distal side branch which can be excluded with covered stent]
    • If extravasation still persists or site of injury is proximal main vessel with bifurcation (covered stent not an option) consider emergent surgery
    • Aggressive treatment with intravenous fluids, atropine, vasopressors, mechanical circulatory support if hemodynamics deteriorate

Burr Entrapment

  • Entrapment consists of burr embedding in a severe stenosis, preventing both further burr advancement and retrieval
  • Presence of diamond chips on the front, but not the rear, of the burr abets an opportunity for the burr to lodge within a lesion and become entrapped.
  • Once stuck and stalled within a lesion, retrograde ablation is not possible and friction associated with retrograde motion cannot be orthogonally displaced.
  • During ablation, the operator should be attentive to potential warning signs, which may be visual (lack of smooth advancement under fluoroscopy), auditory (pitch changes with variation in resistance encountered by burr), or tactile (resistance in advancer knob or excessive driveshaft vibration)
  • Incidence: 0.5% to 1%34
  • Prevention:
    • Meticulous relief of system tension before RA
    • Gentle pecking motions
    • Short ablation runs
    • Avoid excessive tortuosity
    • Do not stop spinning within a lesion
  • Treatment:
    • Apply forceful pull on the Rota wire with guide disengaged taking advantage of the wire’s 0.014 inches spring tip
    • Administer high dose of vasodilators and aggressively pull the Rota burr
    • Manual traction with on-Dynaglide or off-Dynaglide rotation
    • If above measures fail, potential catheter-based solutions to facilitate burr retrieval include
  • Obtain second arterial access and advance Fielder wire and a small (1~1.25mm) balloon distally, inflate at the level of Rota burr, then aggressively pull the Rota burr
  • Advance Guide extension catheters on the Rota Burr

7Fr Guide extension Cut the Rota burr shaft at the connection outside the body, then advance 7Fr guide extension on the shaft until the Rota burr and pull aggressively.
6Fr Guide extension catheter → Cut the Rota burr and aggressively pull the Teflon covering sheath. → once done, then advance 6Fr Guide extension on the shaft until the Rota burr and pull aggressively
  • Subintimal tracking and reentry with balloon dilatation adjacent to the entrapped burr35, 36



References

  1. Shimony A, Joseph L, Mottillo S, Eisenberg MJ. Coronary artery perforation during percutaneous coronary intervention: a systematic review and meta-analysis. Can J Cardiol 2011;27:843–50.
  1. Al-Lamee R., Ielasi A., Latib A., et al. (2011) Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforations. J Am Coll Cardiol 4:87–95
  1. Sharma SK, Tomey MI, Teirstein PS, et al. North American Expert Review of Rotational Atherectomy. Circ Cardiovasc Interv. 2019;12(5):e007448. doi:10.1161/ CIRCINTERVENTIONS. 118.007448
  2. Naito R, Sakakura K, Wada H, Funayama H, Sugawara Y, Kubo N, Ako J, Momomura S. Comparison of long-term clinical outcomes between sirolimus-eluting stents and paclitaxel-eluting stents following rotational atherectomy.Int Heart J.2012; 53:149–153
  3. Tomey MI, Kini AS, Sharma SK. Current status of rotational atherectomy.JACC Cardiovasc Interv.2014; 7:345–353. doi: 10.1016/j.jcin.2013.12.196
  4. Sulimov DS, Abdel-Wahab M, Toelg R, Kassner G, Geist V, Richardt G. Stuck rotablator: the nightmare of rotational atherectomy. EuroIntervention.2013; 9:251–258. doi: 10.4244/EIJV9I2A41
  5. Tanaka Y, Saito S. Successful retrieval of a firmly stuck rotablator burr by using a modified STAR technique.Catheter Cardiovasc Interv.2016; 87:749–756. doi: 10.1002/ccd.26342
  6. Prasan A.M., Patel M., Pitney M.R., et al. (2003) Disassembly of a rotablator: Getting out of a trap. Catheter Cardiovasc Interv 59:463–465