Case 218: Manual of CTO PCI - Retrograde microcatheter entrapment

A patient with ischemic cardiomyopathy was referred for PCI of a right coronary artery CTO due to medically refractory angina. An Impella CP device was used prophylactically with the single access technique to insert a sheath along with left femoral access. Antegrade crossing failed hence retrograde crossing was attempted through the first septal collateral that was jailed from a prior LAD stent. A Caravel microcatheter could not be delivered retrogradely but a FineCross microcatheter crossed into the PDA, followed by successful guide extension reverse CART. However, the FineCross could neither be advanced into the antegrade guide catheter nor withdrawn into the LAD, it was entrapped.
Using the circumcision technique we removed the proximal hub of the FineCross and advanced a guide extension and a 4 Fr catheter, but could not remove the FineCross. We inserted a 2nd wire from the LAD into the first septal and did multiple balloon inflations, but once again we were not able to remove the FineCross. Eventually, at the recommendation of Tony DeMartini, we inserted a guide extension over both the FineCross and the 2nd guidewire, and this time the FineCross was successfully removed. During the retrieval attempts the patient became hemodynamically unstable but he eventually recovered without requiring additional hemodynamic support.

[@shangz0216]

Thanks for the excellent case presentation.

[@maisamtaherian986]

Incredible! 😮 thank you very much. The filling after removing the micro catheter is unexplainable 😊❤

[@fatherabdul]

WOW 🎊 🎉UNBELIEVABLE

[@amrhanafymahmoud9829]

Very challenging case .thank you for learning and helping us

[@karthikeyanselvaraj1801]

Sir..wud a coronary single loop snare over the Circumcised MC be helpful

[@manosbrilakis]

Yes, this could help as well, thank you.

[@mahmoud_elrayes]

Excellent case. 2 questions ; 1- Will microcatheter trapping by TrapLiner®facilitate its safe removal in this case? 2- What will you do in case of complete fracture and detachment of microcatheter inside the septal collateral? Thanks.

[@DreamTheaterTomi]

To the first question i believe the answer is that by pulling hard with trapping there is always a chance to lost gw position. They didnt want to give up

[@DreamTheaterTomi]

2nd: it depends where the mc fractured. Best option: after the LAD stent. In that case i believe it is safe to leave it alone.

[@manosbrilakis]

Great points / if the microcatheter fragment is completely inside the septal would probably leave it in situ - if the fragment continues in the LAD would cover it with a stent.