Management of Lost Atherectomy Devices in the Coronary Arteries

Rotational and orbital atherectomy are important tools to treat calcific coronary disease. Entrapment of an atherectomy device, that is, rotational atherectomy burr or orbital atherectomy crown, is a serious complication during atherectomy. Loss of an atherectomy device is a more challenging complication that usually follows device entrapment. Although uncommon, given the increased adoption of atherectomy, it is important for interventional cardiologist to understand the mechanisms and principles for prevention and management of lost atherectomy devices. Given the paucity of reported cases, there is no clear consensus or defined approach as to how this complication is best managed. The current recommendations for burr/crown entrapment are generally to remove everything from the coronary vasculature and range from different percutaneous strategies and ultimately cardiac surgery. Conservative treatment with leaving the burr within the coronary vasculature has not been recommended. This article serves to review and provide a contemporary update on the management of lost atherectomy devices in the coronary arteries. We review the management and techniques centered around cases of lost atherectomy devices including a unique cohort of patients with lost burrs/crowns that were left in the coronary arteries. Finally, we provide an algorithmic approach to the contemporary management of lost atherectomy devices, incorporating a conservative strategy arm, and discuss situations where this may be considered.