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CASE REPORT
Year : 2023 | Volume
: 24
| Issue : 4 | Page : 221-223
Successful bail out of rotablator driveshaft fracture due to severe calcified lesion and proximal tortuosity
Hiroki Uehara, Masaki Okuyama, Yutaro Oe, Takaki Yoshimura, Takahiro Gunji
Department of Cardiovascular Medicine, Kin-Ikyo Chuo Hospital, Sapporo, Japan
Correspondence Address:
Dr. Hiroki Uehara
Kin-Ikyo Chuo Hospital, Sapporo
Japan
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_28_23
Abstract
A 59-year-old male dialysis patient with a history of coronary artery bypass graft surgery underwent percutaneous coronary intervention of a right coronary artery with a severely calcified lesion. While debulking calcification using a Rotablator, the driveshaft was suddenly fractured. We attempted to move a child-in-mother catheter closer and across a second floppy wire and we dilated a 2.0-mm noncompliant balloon to trap the driveshaft, which we then removed, and restarted the intervention.
Keywords: Calcified lesion, driveshaft fracture, percutaneous coronary intervention
Introduction 
RotaWire has been reported to often rupture depending on rotational speed and the nature of the lesion. On the other hand, the fracture of a rotablator driveshaft is a rare accident. We report a case in which the driveshaft, rather than the wire, was fractured due to severe calcification and flexural lesions.
Case Presentation A 59-year-old male dialysis patient with a history of artery bypass graft surgery (left internal thoracic artery to left anterior descending artery bypass, saphenous vein graft (SVG) to the obtuse marginal branch, 2 years earlier) underwent percutaneous coronary intervention of a right coronary artery (RCA) with a severely calcified lesion. Coronary angiography showed 75% stenosis of RCA #2, and the fractional flow reserve was 0.77. The left circumflex coronary artery and SVG obtuse marginal graft showed occlusion. Therefore, we decided to treat the RCA lesion. Coronary calcification and coronary tortuosity were both severe [Figure 1]a.
Figure 1: (a) Computed tomography revealed severe calcification (red arrow) in the right coronary artery. (b) Right coronary angiography revealed severe stenosis (red arrow). (c and d) Ablation with a rotablator was initiated. (e and f) The driveshaft broke and was salvaged with a child-in-mother catheter. (g and h) The driveshaft was moved out 2 cm from the tipWe inserted a 7-Fr sheath through the right femoral artery and engaged a 7-Fr guiding catheter (Short Amplatz Left 1.0 Launcher; Medtronic, USA). Intravascular ultrasound (IVUS) could not cross the lesion, so we initiated ablation with a Rotablator (Boston Scientific, USA). A 1.5-mm burr successfully crossed the lesion with RotaWire Floppy, with a rotational speed of 180,000 rpm. After 13 ablations, the driveshaft suddenly fractured 2 cm beyond the burr (losing 10,000 rpm of rotational speed) and went out of control. Assuming that the driveshaft might not be stuck, we attempted to move a child-in-mother catheter (Telescope; Medtronic) closer and across a second floppy wire (SION Blue; ASAHI, Japan). We dilated a 2.0-mm noncompliant balloon to trap the driveshaft, which we then removed, and restarted the intervention [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. The RCA was predilated with a 3.50 mm × 15 mm noncompliant balloon and stented with a 3.5 mm × 38 mm drug-eluting stent (Resolute Onyx; Medtronic). The postdilation balloon was a 5.0 mm × 8 mm semi-compliant balloon because the proximal legion was greatly cut by a debulking device (we deemed low-pressure expansion necessary). After the treatment was completed, the driveshaft was moved out 2 cm from the tip [Figure 1]g and [Figure 1]h.
Discussion RotaWire has been reported to often rupture depending on rotational speed and the nature of the lesion. Sakakura et al. reported that RotaWire can be spun under the maximum rotational speed even when the torquer is fixed.[1] This phenomenon can cause wire breakage. On the other hand, the fracture of a rotablator driveshaft is a rare accident. Such fractures generally involve the separation of the burr from the driveshaft; a driveshaft fracture at 2 cm beyond the burr is very rare. We found only one similar case report of driveshaft fracture, a case in which significant tortuosity and enlargement caused driveshaft prolapse.[2] The present case also involved severe tortuosity but without prolapse. We believe that proximal severe tortuosity and calcification stressed the wire and driveshaft. When the rotational speed decreased, wire stress increased, leading to the fracture.
In our case, the calcification was so severe that even IVUS could not pass through the lesion, so intervention without debulking would have been difficult. Changing the wire to extra support may have been a good idea to pass the flexural lesion with less damage to the driveshaft. However, in that case, the wire bias may have been too strong, and the ablation of the inner curvature side may have been too strong. The only solution seems to be careful debulking of the Rotablator strokes as short as possible and as few times as possible.
Conclusion Extra care is needed when a rotablator is used in cases with proximal severe tortuosity and calcification.
Compliance with ethical standards
This article does not contain any studies with human or animal subjects performed by any of the authors. The identity of the patient has been protected.
Acknowledgments
The author would like to thank KN International for editing a draft of this manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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