Rotational Atherectomy for Ablation of a Retained Microcatheter Distal Tip in a Calcified Chronic Total Occlusion

BACKGROUND: Retention of a microcatheter distal tip during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is rare and particularly challenging in heavily calcified, balloon-uncrossable lesions. CASE SUMMARY: A 66-year-old man with symptomatic chronic coronary syndrome underwent PCI for a severely calcified ostial left anterior descending artery CTO. After antegrade wire crossing, the lesion remained balloon-uncrossable. During balloon-assisted wire exchange, the Finecross distal radiopaque tip fractured and remained embedded within the CTO segment. Rotational atherectomy with a 1.5-mm burr resulted in fluoroscopic disappearance of the retained tip while preserving TIMI flow grade 3. Because lesion crossability remained limited, a 1.25-mm burr was used for further plaque modification, possibly because interaction with the retained tip material reduced the initial burr's cutting efficiency. PCI was then completed with stent implantation and an excellent final angiographic result. DISCUSSION: This case highlights rotational atherectomy as a bailout option in calcified uncrossable CTOs, while acknowledging the uncertain downstream risk of fragmented microcatheter material. TAKE-HOME MESSAGE: Controlled plaque modification may permit safe PCI completion when retrieval is impractical.