Management of Microcatheter Fracture in Complex Percutaneous Coronary Intervention With Laser Atherectomy

Microcatheter tip fracture and acute vessel occlusion rescued with subintimal tracking and re-entry: Move the tip

The development of microcatheters capable of advancing through long, calcified, and tortuous vessels, produced an increase in the success rate of complex percutaneous coronary interventions. However, the aggressive manipulation of these materials may lead to potentially severe and threatening complications. We present a case of Turnpike Spiral (Teleflex) tip fracture, which caused an acute occlusion of the proximal right coronary artery. The coronary artery was tortuous and had two heavily calcified lesions in the proximal segment, uncrossable to both small angioplasty balloons and standard microcatheters. After the incarceration of the tip of the Turnpike Spiral in the calcium, it got fractured during the attempt of removing it from the vessel. This led to ST-segment elevation and patient instability. Due to the impossibility of advancing a second guidewire into the true lumen, we decided to proceed to antegrade dissection and re-entry using the scratch-and-go and subintimal tracking and re-entry technique. We placed a guide-extension and we used a Gaia II (Asahi Intecc) to enter the subintimal space and advance over the fractured tip. The wire was exchanged for a Gladius MG (Asahi Intecc), which re-entered the true lumen at the level of the acute margin of the heart. Intravascular ultrasound was used to confirm the re-entry point, and three drug eluting stents were placed. In this way we rapidly restored the flow in the right coronary artery, and we prevented a myocardial infarction.

Global Consensus Recommendations on Improving the Safety of Chronic Total Occlusion Interventions

Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI.

Device entrapment during percutaneous coronary intervention

INTRODUCTION

Device entrapment is a life-threatening complication during percutaneous coronary intervention (PCI). However, the success for its management is predominantly based on operator experience with limited available guidance in the published literature.

METHODS

A systematic review was performed on December 2021; we searched PubMed for articles on device entrapment during PCI. In addition, backward snowballing (i.e., review of references from identified articles and pertinent reviews) was employed.

RESULTS

A total of 4209 articles were retrieved, of which 150 studies were included in the synthesis of the data. A methodical algorithmic approach to prevention and management of device entrapment can help to optimize outcomes. The recommended sequence of steps are as follows: (a) pulling, (b) trapping, (c) snaring, (d) plaque modification, (e) telescoping, and (f) surgery.

CONCLUSIONS

In-depth knowledge of the techniques and necessary tools can help optimize the likelihood of successful equipment retrieval and minimization of complications.