1) The document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs), including equipment loss or entrapment of guidewires, microcatheters, and rotablator burrs. 2) Specific cases are presented where a guidewire became knotted and trapped during a retrograde approach, a microcatheter tip ruptured while attempting to cross a CTO, and a rotablator burr became stuck in the distal coronary artery. 3) Techniques explored to resolve equipment entrapment include wire snaring and retrieval, using a second wire or balloon to free the trapped device, and switching to an antegrade approach or surgery. Care

1. Trapped device: leave it or retrive it?
Andrea Gagnor
Director of Interventional Cardiology Unit
Maria Vittoria Hospital
Turin, Italy

2. I, Andrea Gagnor DO NOT have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of
the subject of this presentation
Disclosure Statement of Financial Interest

3. Equipment loss or entrapment
• Equipment loss or entrapment during CTO PCI
(guidewires, stents and other devices) usually
represent a infrequent circumstance.
• Indeed it is a rarely reported complication in
literature so that its real incidence is unknown
• The risk for this complication is related to lesion
complexity, extent of calcifications, vessel
tortuosity and techniques required for
recanalization.
1. Patel SM et al. J Invasive Cardiol. 2018 Feb;30(2):43-50.
2. Shimony A et al. Can J Cardiol. 2011 Nov-Dec;27(6):843-50.
3. Patel VG et al. JACC Cardiovasc Interv. 2013 Feb;6(2):128-36.
4. Tajti P. Can J Cardiol. 2018 Oct;34(10):1264-1274.
5. Kinnaird et al. JACC Cardiovasc Interv. 2017 Apr 10;10(7):635-644.
Complication Incidence
Perforation 2.9-4.1 %
Donor Vessel Injury 1.1-1.8 %
Equipment loss or entrapment ???
Contrast-induced nephropaty (CIN) 3.4%
Vascular access complications 0.5-1.5%
Radiation skin injury <0.01%
Arrythmia 0.8%
Stroke <0.01%
Urgent CABG 0.1%
Myocardial infarction 2.5%
Death 0.2%

5. Gasparini et al. Eurointerv 2020. In press

6. Guidewires

7. 50 years old male
Prox RCA in stent CTO
Retrograde attempt from septal
Ultimate Bros 3 behind the stent
Knotting of retrograde UB3 wire
Courtesy of Dr Roberto Garbo

8. Wire retrieval...
... but entrapment in
septal !!!

9. Wire DECOILED !!!

10. Retrieval attempts by
snaring through
retrograde guiding
catheter

11. Retrieval attempts by
wire trapping

12. Retrieval attempts by
inflating balloon over
another wire in the
septal branch

13. Retrieval attempts by
snaring through radial
access

14. FINAL RESULT
after LM and LAD stenting

15. 6 months later...
Persistence of effort angina

16. Retrograde approach through
LCx epicardial collateral
Retrograde crossing with
Ultimate3 -> RG3 snaring

17. Final result

18. Courtesy of Dr Gabriele Gasparini
Long LAD CTO post-CABG, Epicardial collateral fro RCA

19. Corsair and GAIA 2nd Retrograde Knuckle with Gaia Tip rupture

20. Antegrade Kissing wire and crossing

21. FINAL RESULT

22. 75 years old female
Previous aortic valve replacement with
degenerated bioprosthesis (Perimount
Magna Ease) and severe aortic
stenosis
Acute Coronary Syndrome
Ostial RCA subocclusion
No way to select ostial RCA with
guiding catheter !
Courtesy of Dr Roberto Garbo

23. Septal collaterals Retrograde crossing (Sion wire)

24. Retrograde wire snaring
and externalization (RG3
wire)

25. Antegrade dilation with 1.0 and
1.25 mm balloons: INEFFECTIVE
Retrograde OTW 1.25 mm balloon
NOT CROSSING THE LESION

26. RG3 WIRE STUCKED
No possibility to retrieve the
wire (entrapped in ostial RCA !)
Hemodynamic destabilization
during retrieval attempts
(pullback with LAD “stretch”)

27. Urgent cardiac
surgery
Need of IABP
support

28. RG3

29. Learning Point
• Drilling of the guidewire in calcified lesions may end in
guidewire tip jailing
• Retrograde wire strong manipulation (Knuckling)
increase the risk of “ wire decoiling”, exp Gaia family
• Usually the residual part of the wire in the coronary
artery doesn’t cause any problem (Try to break the
guidewire as close as possible to the tip)

30. Microcatheters

31. 55 years old male, MID LCx CTO
Courtesy of Dr Pierfrancesco Agostoni
Easy crossing with Fielder XTA but Caravel
does not cross even with rotation…

32. Rupture of Caravel Tip…
Dilation with 1.0 mm to
push the Caravel Tip
further
FAILURE !

33. Bailout Anterograde
Knuckle with Fielder XT
FAILURE !

34. FINAL RESULT:
CARAVEL TIP LEFT
IN CIRCUMFLEX,
PLANNED NEW
ATTEMPT
RETROGRADE

35. Learning Point
• Be careful with Caravel: do not rotate as other
Micro ( it’s braided and not coiled )
• Do not use for Antegrade calcified CTO: the Tip is
fragile

36. 65 years old male, effort angina, EF 45 % Double CTO (RCA and LAD)

37. Ipsilateral Retrograde LAD CTO: Corsair in 2nd septal

38. Ultimate Bros
3 CTO
Crossing

39. Ping Pong technique with UB3 in 2nd
GC, Wire trapped and Strong push and
manipulation to advance Corsair…..
FAILURE !
..Corsair “stucked
with the wire“ and
damaged, not
possible to move
back and forth
everything pulled
out with strong
force

40. Check after
removal
After 60 min
Cardiac Tamponade :
pericardiocentysis but
no need to coil the
septal

41. Learning Point
• Long procedures and strong manipulation can
damage your devices
• If Retrograde Micro cannot cross: change your
Microcatheter before forcing too much
• Don’t use Corsair in tiny and tortuous septal and
epicardial collaterals

42. Child-in-mother

43. ostial Diagonal lesion,
“jailed” by prox LAD
stent
Courtesy Dott. G. Gasparini

44. ostial Diagonal dilatation

49. Rotablator™ burr
entrapment

50. Mid LAD CTO, heavily calcified
Courtesy of Dr Pietro Mazzarotto

51. Retrograde failure, then antegrade
succesfull attempt (“kissing wire”)
Rota Burr 1.25 mm “stucked”
in distal LAD

52. After failure in Gudeliner advancement…
…second wire into LAD, distally to the burr
Balloon inflated alongside the
burr: FAILURE

53. Balloon inflated distal to the burr and retrieval

55. FINAL RESULT

56. Learning Point
• High rotational speed and system coaxiality are
essential to reduce the risk of burr entrapment
• Be careful when treating tandem and long calcified
lesions
• Child in mother technique is very useful to solve
burr entrapment, but sometimes parallel balloon
dilatation and retrieval is a good option

58. Thanks to….
ITALIAN CTO DREAM TEAM !!!
Roberto Garbo
Gabriele Gasparini
Jacopo Oreglia
Pietro Mazzarotto
Pierfrancesco Agostoni

59. Thanks to….
ITALIAN CTO DREAM TEAM !!!
Roberto Garbo
Gabriele Gasparini
Jacopo Oreglia
Pietro Mazzarotto
Pierfrancesco Agostoni