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

Abstract

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.