Retrieval of a stuck Rotablator burr (“Kokeshi phenomenon”) and successful percutaneous coronary intervention

Abstract

We report the case of a 74-year-old man having angioplasty following admission with a troponin positive acute coronary syndrome. Due to heavy coronary artery calcification, rotablation was used. The procedure was complicated by a stuck burr (“Kokeshi phenomenon”). We employed a novel method to safely remove the burr and complete the procedure.

<Learning objective: Various methods have been described for the retrieval of an entrapped Rotablator burr; we show in this case that deep engagement of guiding catheter and manual traction is a safe and effective method for retrieval.>

Introduction

A 74-year-old man with a history of diabetes and hypertension was admitted to our institution with troponin positive acute coronary syndrome. He had a history of sleep apnea and obesity and was on home nocturnal continuous positive airway pressure. Clinical examination was unremarkable. He had normal renal function and subsequent elevation in his high sensitivity troponin. His electrocardiogram (ECG) did not show any acute changes and echocardiography confirmed preserved left ventricular systolic function. Coronary angiogram was undertaken on day 2 and performed via the right radial artery approach with 6Fr catheters. There was heavy calcification noted in the coronary tree. The left anterior descending artery was unobstructed, the left circumflex artery had a significant stenosis in its distal segment, and the right coronary artery (RCA) was severely diseased with calcification and critical serial stenosis and thrombolysis in myocardial infarction (TIMI) grade 2 flow. In view of the history and angiographic findings, we proceeded to percutaneous coronary intervention of the RCA.

Case report

An AL 0.75 guide catheter was utilized at the outset and the RCA was wired with some difficulty using a runthrough wire (Terumo, Tokyo, Japan). We encountered difficulty in advancing a 2.0 Ryujin (Terumo) and subsequently a 1.2 sprinter legend (Medtronic, Minneapolis, MN, USA) balloon due to a hold up in the proximal calcified segment. In view of this, we elected to proceed to rotablation; a finecross (Terumo) was advanced into the proximal RCA and the runthrough wire exchanged for a rotafloppy wire (Boston Scientific, Marlborough, MA, USA). We commenced rotablation with a burr speed of 175,000 rpm. On the second pass, there was significant burr deceleration and the burr became lodged beyond the lesion (Fig. 1). Gentle traction was applied but was unsuccessful in retrieving the burr. At this stage TIMI 1 flow was noted in the distal RCA and the patient started experiencing chest pain with inferior ECG changes. Right femoral artery access was gained using a 7F sheath and a 7F AL 0.75 guide catheter was used to intubate the RCA. We planned to parallel wire the burr with the aim of inflating a balloon beside it to dislodge it, but we were unsuccessful in traversing the stuck burr with a Whisper MS wire (Abbott Vascular, Abbott Park, IL, USA).

Fig. 1.

Entrapped 1.25 rota burr.

In view of the ongoing ischemia, the initial 6F AL 0.75 guide was used to deeply intubate the RCA to cover the burr and then using the guide as an anchor; traction was used to successfully retrieve the burr (Fig. 2). Using this technique, we were able to maintain our distal wire position.

Fig. 2.

6F guide deeply intubated into the right coronary artery to allow traction to be applied. A second guide (AL1 7F) can also be seen.

Due to concerns regarding heavy luminal calcification, we upsized to a 1.5 burr and carried out further rotablation at 175,000 rpm again encountering burr deceleration. The proximal RCA had also become dissected and no further burring was performed. The RCA was parallel wired with the runthrough wire and a 2.6F Tornus catheter (ASAHI Intecc, Nagoya, Japan) was used to create a channel that allowed delivery of a 1.25 and subsequently 2.5 and 3.0 balloons to the distal vessel. Despite adequate balloon preparation, stent delivery was difficult but was overcome with use of the GuideLiner catheter (Vascular Solutions Inc, Minneapolis, MN, USA) which increased co-axiality. This allowed successful deployment of 4 overlapping drug-eluting stents coming back to the ostium of the RCA; the stented segment was post-dilated with 4.0 non-compliant quantum (Boston Scientific) balloons with an excellent final angiographic result (Fig. 3).

Fig. 3.

Final result after delivery of 4 overlapping drug-eluting stents with the aid of a GuideLiner.

Discussion

Entrapment of a rota burr is a rare phenomenon and usually requires surgical removal with subsequent coronary artery bypass grafting. The Japanese have termed this the Kokeshi phenomenon named after a wooden doll found in northern Japan which consists of a simple trunk but a large head akin to the Rotablator. There are interventional techniques available to try and retrieve a lodged burr. The most common one reported in the literature is to use a second access site to allow parallel wiring of the stuck burr and subsequent passage of balloons to release the burr. This technique, however, is difficult due to the lack of luminal space available within the coronary vessel to allow successful passage of further equipment. Other published techniques include disassembly of the Rotablator system; this is usually done distal to the advancer which then allows a heart rail [1] (Terumo), a GuideLiner catheter (Vascular Solutions Inc) [2], or even a goose neck snare (eV3, Plymouth, MN, USA) [3] to be advanced to try and successfully retrieve the entrapped burr using traction. Our technique involved a similar traction method deeply intubating the guiding catheter and applying backward traction to help release the burr. Using this technique, the distal wire position is retained; this is particularly important as release of the burr can result in traumatic injury to the vessel including vessel dissection or even perforation. Our technique may not be applicable in all cases such as those with severe tortuosity in the proximal vessel where delivery of the guide catheter may prove difficult or indeed in ostial lesions. Deep intubation of the guiding catheter also risks dissection of the vessel. However, despite these limitations, we feel that it is a useful technique. An algorithm for the management of an entrapped rotablation burr has recently been proposed [4]. In general terms, there do not appear to be any predictors of burr entrapment in terms of burr diameter or vessel. Burr deceleration, however, is an ominous sign. In our case, the most likely cause of entrapment was probably due to a combination of guidewire bias and vessel wall tortuosity.

We conclude that deep engagement of the guide catheter followed by application of traction is a safe and effective method in the removal of a stuck rota burr.

Conflict of interest

The authors do not have any conflict of interest and have not received any funding for this.