Orbital Atherectomy Through Left Main Stent Struts Complicated by Catheter Entrapment and Stent Avulsion.

We performed orbital atherectomy in the left circumflex artery through a stent that jailed the circumflex artery ostium. The orbital atherectomy catheter was entrapped within the stent and the stent was avulsed during catheter withdrawal. We should consider this potential complication when performing orbital atherectomy in a jailed side branch. (Level of Difficulty: Advanced.).

A 60-year-old woman previously had percutaneous coronary intervention in the left main coronary artery (LM) and left anterior descending artery with implantation of a 3.5 mm × 22 mm Resolute Onyx stent (Medtronic, Santa Rosa, California). Two years later, follow-up angiogram showed severe stenosis in the left circumflex artery jailed by the LM-left anterior descending artery stent (Figure 1A). Intravascular ultrasonography revealed the ostial and mid-left circumflex artery had calcified stenosis (Figure 1B, Video 1). Percutaneous coronary intervention was performed with a Diamondback 360 Coronary Orbital Atherectomy System (CSI, St. Paul, Minnesota). The lesion was crossed with the assistance of a 7-F Guidezilla extension catheter (Boston Scientific, Marlborough, Massachusetts). First, the lesion was ablated at 80,000 rpm. Then, the speed was increased to 120,000 rpm. Suddenly, the catheter became entrapped within the LM stent struts (Video 2). The double guiding catheter technique was performed. Another wire was advanced across the stent and a 2.25-mm balloon was inflated. However, the catheter still could not be withdrawn. Intravascular ultrasonography was performed using the parallel wire and revealed that the stent had been avulsed and was wrapped around the catheter (Figure 1C, Video 3). Finally, we exchanged the Guidezilla for a Guideplus (Nipro, Osaka, Japan) and pulled and pushed the Guideplus, which succeeded in withdrawing the Orbital Atherectomy catheter (Figure 1D). We implanted 3 drug eluting stents, which resulted in sufficient lesion dilatation by angiography with TIMI (Thrombolysis In Myocardial Infarction) flow grade 3.

Figure 1

Coronary Angiogram, Intravascular Ultrasonography, and Retrieval of Entrapped Orbital Atherectomy Catheter

(A) Stenosis in left circumflex artery (LCX) (black arrows). (B) Calcified stenosis at the ostial lesion (white arrows). (C) Orbital atherectomy catheter (white arrow) with metallic mass (white arrowheads) in left main coronary artery and absence of left main stent struts (yellow arrowheads). (D) Withdrawn stent (black arrows) and orbital atherectomy catheter (white arrows). The proximal part of the stent was wrapped around the catheter (white arrowheads). LAD = left anterior descending.

Online Video 1

Online Video 2

Online Video 3

Pre-Procedural Intravascular Ultrasonography

Intravascular ultrasonography revealed ostial and mid left circumflex artery lesions had calcified stenosis.

Angiogram of the Orbital Atherectomy

The angiogram showed that the catheter became entrapped within the LM stent struts and it could not be removed.

Post-Atherectomy Intravascular Ultrasonography

Intravascular ultrasonography revealed orbital atherectomy catheter with metallic mass in left main coronary artery and absence of left main stent struts.

A similar complication with a cutting balloon catheter was previously reported (1). This potential complication should be considered when evaluating whether to perform orbital atherectomy in a jailed side branch, especially when the side branch has an obtuse angle.