Fracture of Rotational Atherectomy Burr: Pre-Fracture Signs, Mechanisms, and Management Strategies.

Abstract

Background: Burr fracture during rotational atherectomy (RA) is a rare but potentially devastating complication. Due to its infrequency, comprehensive data on its incidence, mechanisms, and management are lacking. This study aimed to investigate the incidence, contributing factors, and management strategies for burr fractures during RA procedures.

Methods: This retrospective analysis included all patients who underwent PCI with RA at a single center between January 2013 and October 2024. Data were collected from a prospective registry.

Results: Among 3738 patients, three cases of burr fracture without entrapment were identified (incidence: 0.08%). Burr fractures occurred at the burr-driveshaft junction (tip fracture) in two cases and at the driveshaft in one case. Pre-fracture warning signs included incoherent burr-advancer knob movement, fluoroscopic translucency, and frequent driveshaft prolapse. Significant proximal tortuosity or enlargement and non-coaxiality between the RA device and the coronary artery were identified as potential contributing factors. In two cases involving tip fractures, simple manual traction removed the fractured burr. In the third case involving driveshaft fracture, coronary rupture necessitated covered stent implantation and urgent surgery.

Conclusion: Burr fractures during RA are rare but potentially serious complications. Significant proximal tortuosity or enlargement and non-coaxiality between the RA device and the coronary artery may increase the risk of burr fracture. Recognizing pre-fracture warning signs and understanding the underlying mechanisms are crucial for minimizing complications and optimizing procedural safety.