Introduction The orbital atherectomy system (OAS) is a device used to ablate calcified coronary lesions during percutaneous coronary interventions (PCI). Optimal calcified plaque modification facilitates optimal stent placement and expansion. Nevertheless, its utility carries an uncommon risk of crown entrapment which may require a snare or an invasive surgery for its retrieval. This report describes a successful case of retrieving an entrapped diamond crown, which is detached from its wire, using a microcatheter.

Case Presentation A 60-year-old gentleman with a non-ST elevation myocardial infarction underwent coronary angioplasty for a severely calcified right coronary artery with diffuse stenosis. Amplatz Left 1 (AL 1) was engaged and the lesion was prepared using the Diamondback 360 Orbital Atherectomy System. The atherectomy was performed at 80,000 rpm with progressive escalation up to 120,000 rpm, at which point the system experienced an abrupt halt. Withdrawal of the crown results in a breakage that separates the crown from the atherectomy system leading to crown entrapment. Angiography revealed a sealed perforation in the target lesion. Due to the unavailability of a snare, a FineCross microcatheter was advanced over the OAS traction wire toward the trapped crown. The crown was successfully captured and retrieved as it adhered to the microcatheter. Final angiography showed a concealed perforation with TIMI 2 flow.

Discussion Coronary artery calcification emerges as a sequela in the genesis of atherosclerotic plaque. Its emergence is contributed by several factors such as advanced age, diabetes mellitus, hypertension, and chronic kidney disease. The two distinct types of calcifications are vascular intimal and medial calcifications, with the former being more commonly found. Owing to the risk of major adverse cardiovascular events contributed by the presence of moderate to severe coronary artery calcifications, an orbital atherectomy has been introduced as a calcified plaque modifying device before coronary stent implantation. Equipped with a diamond coated crown, it rotates over its guidewire in a centrifugal pattern, crushing the calcified plaque. Breakage of the device component accounts for 40% of the complications, entrapment of device occurs in 8% of cases, and breakage with subsequent entrapment of the device pieces represents 0.4% of its complications.

Conclusion Crown entrapment is a serious consequence of atherectomy that requires a suitable device for its retrieval.