Unexpected complication- fracture of the IVUS catheter and percutaneous retrieval of a broken IVUS catheter tip from the right coronary artery/Beklenmedik komplikasyon-IVUS kateterinin kirilmasi ve perkütan yolla, sag koroner arterden kirik IVUS katater parçasinin çikarilmasi

Fracture of the IVUS catheter is very rare and, but when occurs they may lead to life-threating complications, such as embolization, thrombus formation and perforation. A 58-year-old man who had history of smoking, dyslipidemia and type II diabetes mellitus presented with an inferior ST-elevation myocardial infarction and underwent emergent coronary angiography. His coronary angiography showed nonsignificant stenosis of the mid portion of leftanterior descending artery and 60% stenosis of the mid portion of the right coronary artery (RCA) (Fig. 1, Video 1. See corresponding video/movie images at www.anakarder. com). A complex RCA lesion was suspected, prompting further interrogation with the use of intravascular ultrasound (IVUS) catheter. A 7 French (F) JR 4.0 cm guiding catheter was engaged in the RCA and a floppy guidewire was inserted into the RCA. When the 2.9 F iMAPIVUS catheters (Boston Scientific, Santa Clara, CA, USA) were withdrawn under fluoroscopy without resistance, the distal marker IVUS catheter was separated and this segment was moved toward the postero- lateral artery (Fig. 2, Video 2. See corresponding video/movie images at www.anakarder.com). We realized the tip of IVUS catheter had broken off. A variety of catheter devices, including the loop snare catheter, basket catheter and grasping/biopsy forceps was developed and using these devices, foreign bodies could be retrieved cooperatively safely and promptly. Percutaneous retrieval of the broken segment was attempted. Snare catheter was passed over the guidewire and inserted through a 4F transport catheter. The loop snare caught the IVUS catheter tip securely and resulting in the successful retrieval of the IVUS catheter tip (Fig. 3, 4, Video 3. See corresponding video/movie images at www.anakarder.com). The common mechanism of broken IVUS catheter includes malopposed stent struts, catheter deformation from multiple uses, catheter entrapment in the calcific segment and forceful manipulation. In this case possible mechanisms of this complication are warming of the catheter due to long operation time and catheter deformation from multiple uses. In conclusion we suggest that multiple use of IVUS catheter should be avoided.

Video 1. Right coronary angiography revealed a 60% stenosis of mid portion of the right coronary artery

Video 2. During withdrawn of the catheter, the distal marker of IVUS catheter was separated and this segment was moved toward the PLA IVUS - intravascular ultrasound, PLA - postero-lateral artery

Video 3. Loop snare catheter was passed over the guidewire and inserted through a 4F transport catheter