Successful removal of entrapped Burr with sheathless guiding during stent rotablation

A 75-year-old male patient with a history of hypertension and hypercholesterolemia was referred to our centre with ACS. During previous interventions, a cutting balloon (CB) dilatation, noncompliant (NC) and drug-eluting balloon dilatations, and an NC balloon dilatation with drug-eluting stent implantation (DES, Xcience 4x18 mm, Abbot Vascular, USA) of the mid-right coronary artery (RCA) had been performed. Upon admission, TR coronary angiography revealed a significant lesion in the mid-RCA with stent underexpansion and nonsignificant lesions in the left coronary system (Fig. 1a). Ad hoc RCA PCI was performed. The coronary ostium was engaged with a 6 French Judkins right guiding catheter (JR 6F, BSC, USA), and a 0.014′′ hydrophilic support guidewire (GW) (Whisper ES, Abbot Vascular, USA) was used to cross the lesion with the aid of a balanced middle weight (BMW) GW as a buddy wire. High-pressure (up to 30 atmospheres) inflations with an NC Trek (Abbot Vascular, USA) balloon and a Flextome CB (BSC, USA) failed to modify the target lesion (Fig. 1b). To evaluate further, intravascular ultrasound (IVUS) was performed, which identified an underexpanded stent covering a fibro-calcified RCA stenosis (Fig. 1c, d). As a bailout solution, IVUS-guided TR RA was performed. An 8.5 Fr sheathless AL1 guide (SG) (Asahi Intec Co., Aichi, Japan) was introduced into the RCA orifice, and the lesion was crossed with an extra support Rota wire (BSC, USA). After high-speed RA with an initial 1.5 mm Burr, the lesion was still resistant to NC balloon dilatation (Fig. 2a). Rotablation was upsized to a 2 mm Burr. After a few attempts of a seemingly successful RA, the burr was entrapped into the stent struts (Fig. 2b, c). After positioning the guide as close as possible to the entrapped device (deep intubation), turbine pressure was increased, and under gentle pullback, the burr was finally disengaged. The procedure was finished with a final CB and NC balloon dilatation (3.5×10 mm Flextome Cutting balloon, BSC, USA), and DES (Promus Premier 4.0×20 mm, BSC, USA) was implanted (Fig. 2d, e). The final IVUS scan revealed successful ablation of both the former metallic and calcified rings (Fig. 2f, g). Angiography showed no residual stenosis and confirmed a TIMI III flow. The patient remained asymptomatic during his 2-year follow-up. Successful removal of entrapped Burr with sheathless guiding during stent rotablation