Guidewire Traction Retrieval of a Dislodged Classic Crown During Coronary Orbital Atherectomy

Introduction

Severe calcific coronary artery disease remains a major challenge in percutaneous coronary intervention (PCI). Heavily calcified plaques hinder stent expansion and apposition, increasing the risk of restenosis and thrombosis [1]. Atherectomy devices are often used to modify such lesions and improve PCI outcomes. Orbital atherectomy (OA) utilizes a diamond-coated, eccentrically rotating crown to ablate calcific plaque and facilitate optimal stent delivery [2,3]. The ORBIT II trial demonstrated the safety and efficacy of OA in heavily calcified lesions, with high procedural success rates and low adverse event rates [4].

Nevertheless, OA carries potential risks, including coronary dissection, perforation, and device fracture [2,3]. An analysis of the United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database (2019–2022) showed that device-part breakages – wires, driveshafts, or crowns – contributed to around 40% of OA failures, with crown detachment in approximately 12% [5] (ie, ~4.8% of all reported OA device failures). To our knowledge, only 3 peer-reviewed coronary case reports have documented crown detachment or a stuck crown within the coronary OA system, along with successful percutaneous retrieval [6–8]. Given the risk of embolization, vessel occlusion, or emergent surgery, rapid recognition and effective management are essential. Here, we describe a rare case of crown detachment during OA that was successfully retrieved percutaneously via guidewire traction. This case underscores the importance of preparedness for device-related complications and highlights a bailout technique when standard retrieval methods fail.

Case Report

A 70-year-old man with hypertension, hyperlipidemia, and end-stage renal disease on hemodialysis – as well as a history of 3-vessel drug-eluting stent implantation 3 years earlier – was referred for coronary angiography during preoperative assessment for elective total knee arthroplasty. Angiography revealed a critical, heavily calcified 90% stenosis in the proximal right coronary artery (RCA; segment #1, Figure 1A). After total knee arthroplasty, PCI of the RCA was undertaken via right femoral artery access with a 7-Fr SAL 0.75 SH guiding catheter (ASAHI Hyperion, ASAHI INTECC, Japan). Intravascular ultrasound confirmed circumferential calcification (Figure 1A), prompting the decision to perform OA prior to stenting.

A Caravel MC microcatheter (ASAHI INTECC) was advanced, and the wire was exchanged for a ViperWire Advance Flex Tip OA guidewire (Cardiovascular Systems, Inc., USA). OA was performed using a Diamondback 360 coronary orbital atherectomy system (Cardiovascular Systems, Inc.). At low speed (80 000 rpm), 2 pullback ablation runs were successfully completed. During a third forward pass, fluoroscopy revealed gradual separation of the crown and part of the driveshaft from the catheter shaft, leaving the detached crown lodged at the lesion. The remaining catheter was withdrawn, whereas the crown and OA guidewire remained in the coronary artery (Figure 1B). This forward advancement was performed under active low-speed orbital atherectomy for plaque modification. Because intravascular ultrasound demonstrated concentric, circumferential calcification, we judged that controlled orbital sanding could be performed with acceptable safety under careful fluoroscopic monitoring, while recognizing that manufacturer recommendations generally favor controlled pullback runs.

The patient remained asymptomatic with stable hemodynamics. Distal access was secured by advancing a 0.014-inch buddy wire alongside the trapped OA wire beyond the dislodged crown. To facilitate device passage, the calcified segment proximal to the crown was predilated with a 2.5×12 mm noncompliant balloon. The first retrieval attempt utilized a 4-mm Amplatz Goose Neck snare (Medtronic, USA) introduced through the guide catheter, but multiple passes failed because the tortuous, calcified proximal segment prevented engagement of the crown (Figure 1C). A second strategy used an anchor-balloon technique with a 7-Fr Telescope guide extension catheter (Medtronic). A small compliant balloon was advanced distal to the crown over the buddy wire and inflated to anchor the guide extension. Nevertheless, the rigid calcified bend prevented the extension catheter from reaching the crown, rendering this approach unsuccessful (Figure 1D).

As a final strategy, we attempted guidewire traction retrieval using the existing OA guidewire, with the buddy wire maintained for support. Under continuous fluoroscopic guidance, gentle traction was applied to the ViperWire Advance Flex Tip (Cardiovascular Systems, Inc.), allowing the detached crown to gradually move and be drawn en bloc into the guiding catheter (Figure 1E). The fragmented crown was successfully retrieved without complications. No coronary dissection, distal embolization, or no-reflow was observed after wire traction.

After crown retrieval (Figure 1F), definitive treatment of the lesion was performed. The original 7-Fr guiding catheter – damaged during traction – was exchanged for a 6-Fr SAL 0.75 SH ASAHI Hyperion catheter (ASAHI INTECC). Predilation with a 2.5×12 mm noncompliant balloon created visible plaque cracks on intravascular ultrasound. A 2.5×18 mm XIENCE Sierra drug-eluting stent (Abbott Vascular, USA) was then implanted at the RCA ostium, followed by sequential postdilation with 2.5×12 mm and 3.0×10 mm noncompliant balloons to optimize expansion (Figure 1G). Final angiography demonstrated Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow without residual stenosis, dissection, or perforation (Figure 1H). The patient remained stable and lacked chest pain or enzyme elevation. The next day, he was discharged to the orthopedic ward. At the 1-month follow-up, he was free of angina.

Discussion

In the present case, severe circumferential calcification and tortuosity of the proximal RCA likely promoted wire bias and localized stress at the crown-shaft junction, resulting in detachment of the OA crown and part of the driveshaft. When treating tortuous, heavily calcified segments, the choice of atherectomy modality is clinically important [2,3]. Rotational atherectomy ablates only in the forward direction. Although rare, burr entrapment has long been recognized; historical series have shown rates of approximately 0.4% in complex lesions [9–11]. In contrast, OA permits bidirectional “differential sanding,” allowing pullback during calcium modification and potentially reducing entrapment risk relative to purely forward ablation [2,3]. However, OA may be complicated by crown immobilization, in which the rotating crown cannot be advanced or withdrawn if it overengages rigid calcium or encounters sharp vessel angulations [5–8]. Both platforms share class-typical complications, including dissection, perforation, and slow or no-reflow [2,3]. Reported slow/no-reflow rates with rotational atherectomy range from 6% to 15% in earlier series [9,11]. In the ORBIT II trial, the rate of persistent slow/no-reflow with OA was below 1% (approximately 0.7%) [4], underscoring the generally favorable safety profile of OA in contemporary practice.

With OA, driveshaft fracture is rare but can be clinically significant. An analysis of the FDA MAUDE database revealed that the most frequent category of OA device failure was component separation or breakage (approximately 40% of reports). The majority involved the ViperWire tip (~66%), followed by the driveshaft (~23%) and the crown (~12%) [5]. Mechanistic studies have shown that high-speed rotation in tortuous, circumferentially calcified segments can concentrate bending forces at the crown-shaft junction, predisposing the device to metal fatigue and structural failure; crown detachment under these conditions has been documented [6,7]. According to manufacturer labeling and the FDA Summary of Safety and Effectiveness Data guidance, operators are advised to perform short, intermittent runs; ensure adequate ViperSlide lubrication; and avoid prolonged high-speed ablation in severely rigid or angulated vessels. Adherence to these precautions may reduce the risk of overheating, fatigue, and component separation [12,13]. Additionally, excessive force on the device shaft should be avoided because forced advancement in rigid, angulated calcified segments can increase mechanical stress and contribute to driveshaft fracture or crown separation.

Retrieval strategies for crown detachment have been described in prior case reports. One commonly used method is snaring with the aid of a guide extension catheter. For example, Shishido et al successfully retrieved a detached OA crown by advancing a snare through a GUIDEPLUS guide extension catheter [6]. Another approach is the buddy wire and microcatheter technique, in which a second wire is passed beyond the fragment and a microcatheter is advanced over the primary wire into the hollow crown, allowing the crown, microcatheter, and wire to be withdrawn together; Hirai et al achieved success with this method [7]. In the present case, neither a standalone snare nor an anchor-balloon-assisted guide extension could be advanced due to the rigid calcified bend and pronounced tortuosity of the proximal vessel. Ultimately, simple traction on the existing OA wire enabled safe dislodgement and retrieval of the crown. This feasibility is attributable to a device-level characteristic of the OA system: the geometry of its dedicated guidewire. Nevertheless, guidewire traction carries potential risks (eg, guidewire fracture, vessel injury, or crown loss if excessive force is applied); it should be reserved for carefully selected, hemodynamically stable cases and performed gently under continuous fluoroscopic guidance with surgical backup available.

The dedicated OA system guidewire, the ViperWire Advance Flex Tip (coronary), has a radiopaque distal spring tip (Ø0.014 inches) that is slightly larger in diameter than its 0.012-inch main shaft [12]. This enlarged distal segment functions as a mechanical stop, preventing a detached crown from migrating beyond the wire tip and thus enabling traction-based or snare-assisted retrieval [12], as illustrated in the present case. Both manufacturer documentation and regulatory summaries emphasize the importance of using the compatible ViperWire to maintain this geometry and tracking behavior during OA system operation [12,13]. Taken together, the combination of severe tortuosity and circumferential calcification likely contributed to crown-shaft stress and subsequent detachment, whereas the specific geometry of the ViperWire appears to have facilitated successful traction-based retrieval when snaring could not be advanced.

Conclusions

OA facilitates stent delivery in severely calcified coronary lesions but is associated with rare complications, such as crown detachment. The present case highlights successful use of simple guidewire traction to retrieve a fractured OA crown, avoiding surgical intervention. Optimal outcomes with atherectomy require meticulous preparation, careful technique, and readiness to manage device-related complications. When conventional retrieval strategies are unsuccessful, gentle traction on the dedicated guidewire under continuous fluoroscopic guidance may provide a safe and effective bailout option. Although the short-term procedural outcome was favorable, long-term follow-up observations were limited because the patient died of pneumonia approximately 6 months after the index procedure, unrelated to the coronary intervention.