Retrieval of trapped and broken guide wire with immediate rescue off-pump coronary bypass surgery

Consequences and management of guidewire fracture-entrapment in the left circumflex artery: a case report

Background

Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%.

Case summary

A 52-year-old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the left main/left ascending artery area, likely caused by the coronary snare. These interventions were crucial in stabilizing the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up.

Discussion

Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal; however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.

Safe and predictable transcatheter removal of broken coronary guidewires: the 'knuckle-twister' technique: a case series report

Background

Guidewire fracture and loss is a rare but well-known and feared complication of percutaneous coronary interventions. With the increasing number of complex coronary interventions and procedures for chronic total occlusions, operators face new challenges and boundaries, and the need for solutions to otherwise rare complications is increasing.

Case summary

We have developed a simple and practical method for retrieving fractured and lost guidewires, called the 'knuckle-twister' technique. This article summarizes seven cases in which guidewires lost in the coronary vasculature have been successfully removed and describes this technique in detail. The goal was to gather different clinical scenarios: free wire lost in situ, wire jailed behind stent struts, wire in small branches, part of the wire protruding into the aorta, 'invisible' guidewire microfilaments/coils, etc.

Discussion

The innovation of the knuckle-twister consists in folding a polymer-jacketed guidewire and transforming it into an open lasso that tightens when twisted. In vitro, its grip strength and pulling force was tested and exceeded 1.5 kg. Moreover, in all in vivo cases, the lost material could be efficiently and quite rapidly retrieved with this simple and highly reproducible technique.

Key clinical message

Broken guidewires that were lost in the coronary vasculature can be safely retrieved with this novel and simple technique requiring no special safety equipment.

Lost in circulation

BACKGROUND

Device complications in complex percutaneous coronary interventions are rare but potentially deadly. Surgical removal is often required. However, an evaluation of surgical therapy beyond case reports is practically not existent.

METHODS

We prospectively followed all cases of retained guide wires and/or other devices referred to us for surgical removal between 2015 and 2019 and retrospectively searched our database for such cases between 2010 and 2014.

RESULTS

From 2015 on, eight cases were referred for surgical removal from six different cardiology departments. In the 5 years before, there was not a single case. Six patients were operated emergently. Patients were 60.5 ± 5.42 years old, overweight (body mass index 30.1 ± 3.77) and except for one case (left ventricular-assist device) showed preserved ejection fraction (EF) (mean EF 57 ± 18.01). The retained devices were mostly located in the right coronary artery (50%), followed by the circumflex artery (37.5%) and diagonal branch (12.5%). The devices were remnants of guide wires (n = 4), balloon catheters (n = 3), and in one case a rotablator. Full sternotomy was performed in six patients and two received a left-sided minithoracotomy (n = 2). The operations were performed on-pump in five (62.5%) and off-pump in three patients. Complete extraction of the foreign bodies was possible in all patients. Two patients died; one in unrelated multiorgan failure and one due to retained-device-related right heart failure. The other patients survived and had uneventful postoperative courses.

CONCLUSIONS

Retained foreign bodies from cardiac interventions can be completely removed surgically using individualized approaches. There appears to be a trend toward a rising incidence of such interventional complications.

Surgical rescue of guidewire in-stent entrapment during coronary angioplasty

During a percutaneous coronary procedure, the device may become stuck and break in the coronary circulation. This complication occurs in 0.1% of all procedures. Even with technological improvements, this event still happens because percutaneous coronary interventions are frequently used to treat complex lesions. We report a case of a patient undergoing a percutaneous stenting procedure in which the 0.014″ guidewire was caught in the right coronary artery. Removal of the guidewire was impossible, and it broke in the brachiocephalic artery. Emergency coronary artery bypass grafting was performed.

Successful device retrieval using simple balloon method during cardiac procedures

Objectives

Although rare, incidents of broken/dislodged fragment of various angioplasty hardwares, including catheters, guidewires, angioplasty balloons, and stents, are being increasingly reported in recent years. Since these broken fragments may cause life-threatening consequences for a patient, it is vital for an interventional cardiologist to be acquainted with different retrieval techniques. Here, we are reporting our observations of several incidents of device dislodgement/fracture during cardiac interventions and their retrieval using simple balloon method.

Methods

We present a study of eight patients in whom we attempted to retrieve dislodged/fractured cath-lab hardwares during cardiac interventions, using simple balloon method. These cases include two cases of balloon, three cases of stent, and three cases of guidewire dislodgement/fracture.

Results

Fractured/dislodged cath-lab hardwares were successfully retrieved using a simple balloon method in six out of eight cases (75%), without any need of other retrieval hardwares. We observed no major complications in any patient.

Conclusions

The balloon-assisted retrieval method is a simple, safe, and cost-effective way to avoid complications of endothelial injury, myocardial infarction, emergency coronary artery bypass graft, and sudden cardiac death. This study, particularly the context of retrieval technique used in each case, will offer valuable information to fellow interventional cardiologists.

Successful Retrieval of Uncoiled Coronary Guidewire Using Simple Balloon Method

Breakage of angioplasty device in coronary artery can cause panic in the catheterization laboratory. These broken fragments may serve as a nidus for thrombus formation; hence, removal of these fragments becomes mandatory. Since the incidence of guidewire fracture during angioplasty are rarely reported, evidence-based approaches are not available for the management of such incidental conditions. Here, we report an interesting case of entrapment and unravelling of guidewire. We successfully retrieved unravelled guidewire using a noncompliant balloon inflated in the guiding catheter. Subsequently, the procedure was completed successfully with an implantation of a stent in the culprit lesion. We are of opinion that this novel technique is quite easy and less cumbersome than other described techniques reported earlier.

A rare instructive complication of balloon catheter fracture during percutaneous coronary intervention

The entrapment, fracture, and dislodgement of catheterization devices during percutaneous coronary intervention (PCI) are rare complications, for which cardiac surgery is sometimes required. Here, we encountered a rare but instructive case of balloon catheter fracture during PCI. Although there have been some reports of guidewire fracture in PCI, reports on balloon catheter fracture are very rare to our knowledge. A simulation test to examine the mechanism of balloon catheter fracture revealed that overuse of the balloon catheter, both for kissing balloon inflation and balloon anchor, was highly likely to have been the cause of the fracture.