E-Science Station

Mr. M

Mr. M, a 75-year-old gentleman with a history of myocardial infarction, hypertension, hyperlipidaemia and diabetes mellitus on good medical therapy. Previously, he had a PCI procedure with a stent put in his OM in 2000. This time, he presented to our unit for stable effort angina in 2018. Physical examination was unremarkable with no murmurs or heart failure symptoms.

A MIBI scan was performed for his exertional angina which showed a large septal and apical perfusion defect. The affected myocardium was up to 33%. The eGFR, hemoglobulin were unremarkable. ECHO showed an LVEF of 38% with anterior wall hypokinesia, no significant valvular defects were observed. He was brought in for coronary angiogram as well as percutaneous coronary intervention.

Diagnostic coronary angiogram showed mLAD CTO with J-CTO score of 3 (blunt stump, length and calcification). In view of his symptoms, CTO PCI was planned using antegrade approach with bilateral injection. The CTO was eventually crossed with Gaia 2 supported by Caravel microcatheter.
However, the Caravel microcatheter failed to advance through the lesion despite manipulation. Upon withdrawal of the microcatheter, the tip of the catheter broke off and remained in the vessel inside the lesion.

It was noted that the tip of the microcatheter broke off and was stuck inside the mLAD lesion. Twisted wire technique would unlikely be feasible in this situation since a second wire would be difficult to manipulate inside a CTO body to cause twisting of the wire tips together and even if the wires are twisted together, it would be doubtful that the entire contraption would be able to pulled back through the CTO lesion. Microsnare also would have little purchase on the smooth microcatheter tip. We decided to try using rotablation to destroy the tip. A rotablator wire was passed through the lesion, likely through the tip of the
microcatheter and a 1.5 mm burr was used to rotablate the broken Caravel tip as well as the CTO lesion at 180 000 rpm with multiple passes. Further balloon dilatation and the mLAD lesion was stented with 2.5 x 38 and 2.75 x 15 stents, and TIMI 3 flow was achieved.
Caravel tip.avi

To our knowledge, this is the first case to use rotablation for bailing out a stuck device inside a coronary lesion. We will continue to monitor the patient and will bring the patient back later for a follow up angiogram to assess the condition of the stents.