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 However, the FineCross could neither be advanced into the antegrade guide catheter nor withdrawn into the LAD, it was entrapped.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.