Broken arrow: Successful retrieval of a dislodged coronary orbital atherectomy microtip

Abstract

A 68-year-old female with a history of coronary artery disease and prior bypass surgery presented for staged percutaneous coronary intervention (PCI) to a calcified and angulated ostial left circumflex (LCX) artery lesion after PCI of the anastomosis of the left internal mammary artery - to left anterior descending artery. Orbital atherectomy of the LCX was performed at a speed of 80,000 RPM with multiple passes, and was complicated by device microtip dislodgement and entrapment within the vessel. After advancing a "buddy" wire beyond the microtip, a tapered microcatheter was advanced over the ViperWire and into the edge of the broken microtip and torqued into the microtip with forward pressure using the 0.014 in ViperWire tip as a "backstop." The guidewire, microcatheter, and microtip were then successfully removed as a unit and the intervention with stent placement was completed over the "buddy" wire. Scanning electron microscopy of the shaft revealed evidence of cyclic fatigue, indicating that the fracture occurred while spinning. The fracture when performing atherectomy in a model coronary artery with a radius of approximately 6 mm. This represents a first case of microtip dislodgement and entrapment during the use of a coronary orbital atherctomy device.short.

Coronary Intra-orbital Atherectomy Complications and Procedural Failure: Insight From the Manufacturer and User Facility Device Experience (MAUDE) Database

“…Fractures and dislodgement of the device crown have also been reported as complications of the Diamondback 360® orbital atherectomy system [28][29][30][31]. Most commonly, the crown became fully detached and would remain within the target vessel.…”

“…Significant tortuosity and uneven plaque morphology have been found to increase the risk of crown fracture. Furthermore, to target these plaques, more bidirectional passes are required, yet the crown detachment risk significantly increases after 20 passes within five minutes, according to the manufacturer [ 11 , 29 ]. Therefore, operators must balance lumen clearance expectations with these device limits to prevent crown-related complications.…”

“…Therefore, operators must balance lumen clearance expectations with these device limits to prevent crown-related complications. Removal of the broken crown was successfully done with the use of a gooseneck snare over a newly inserted guidewire catheter in one case or using a tapered microcatheter to capture the tip over the same ViperWire as a device in another case [ 28 , 29 ]. Shlofmitz et al also provide significant instruction on device techniques to minimize the incidence of crown complications.…”