Abstract
Guidewire fracture is an uncommon, yet feared complication of percutaneous coronary intervention that may be more likely to occur in complex lesions and when guidewires interact with newly deployed or pre-existing stents. Wire fragments can often be retrieved using percutaneous techniques, but may need to be removed surgically in case of percutaneous retrieval failure. We present two cases of guidewire entrapment and fracture. In the first case the fractured polymer-jacketed guidewire was successfully retrieved, after crossing the lesion with another guidewire and performing balloon dilation next to the entrapped guidewire. In the second case, attempts for percutaneous guidewire retrieval failed. The wire fragment protruded into the ascending aorta leading to emergent cardiac surgery. We also reviewed the published literature on guidewire fracture and entrapment since 2007, providing an update on risk factors, consequences, and managements of this complication.
Highlights
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Guidewire fracture may occur with greater frequency in complex lesions.
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Retained wires may be removed percutaneously, surgically, or left in situ.
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We present two different cases of guidewire entrapment and fracture.
1
Introduction
Guidewires are essential for performing percutaneous coronary interventions (PCI) and have been evolving at a rapid pace. There are several guidewire types, such as workhorse guidewires with soft, atraumatic tips, polymer-jacketed guidewires that are often used to form knuckles, and stiff-tip guidewires with excellent penetration capacity, often used during chronic total occlusion (CTO) percutaneous coronary interventions (PCI). An uncommon, yet potentially life-threatening complication of guidewire utilization is guidewire entrapment and fracture, which may be more likely to occur in CTOs, heavily calcified and tortuous vessels, and bifurcation lesions . Retained guidewire fragments can be highly thrombogenic leading to coronary occlusion or systemic embolization. Retrieval of the retained guidewire fragment(s) is recommended in most cases and should ideally be achieved using percutaneous techniques, although in some cases surgical removal may be required . We present two cases of guidewire entrapment and fracture that highlight the associated risks and techniques for managing this complication.
2
Case 1
A 69-year-old man with a history of diabetes mellitus type 2, hypertension, rheumatoid arthritis, and coronary artery disease underwent preoperative cardiac evaluation prior to lung biopsy for a pulmonary nodule. Coronary angiography demonstrated a CTO of the mid left anterior descending artery (LAD) without other significant disease. Myocardial perfusion imaging revealed a large area of anteroseptal and apical ischemia. The patient was referred for CTO PCI.
Bilateral femoral arterial access was obtained with 8 French sheaths. The right coronary artery (RCA) was engaged with an 8 French JR 4 guide catheter and the left main coronary artery with an 8 French XB 3.5 guide catheter. Dual injection revealed a 30 mm long occlusion with calcification ( Fig. 1 A ). Antegrade wire escalation with a Fielder XT guidewire (Asahi Intecc) advanced through a Finecross microcatheter (Terumo) resulted in subintimal guidewire entry. A knuckle was formed with the Fielder XT guidewire to attempt subintimal guidewire crossing. The guidewire failed to advance through the occlusion, but could not be withdrawn into the microcatheter and upon further retrieval attempts it fractured, with the distal segment remaining embedded into the occlusion ( Fig. 1 B). The CTO was crossed with a parallel Pilot 200 guidewire (Abbott Vascular, Santa Clara, California, Fig. 1 C) and multiple balloon inflations were performed in an attempt to “free” the entrapped guidewire ( Fig. 1 D). Attempts were also made to push the guidewire fragment into the occlusion with a plan to cover it with a stent. Eventually, the Finecross catheter was removed together with the guidewire fragment ( Fig. 1 E). After implantation of three drug-eluting stents (2.25 × 30 mm, 2.5 × 30 mm, 2.75 × 30 mm), an excellent final result was achieved ( Fig. 1 F). The patient had an uneventful recovery.
2
Case 1
A 69-year-old man with a history of diabetes mellitus type 2, hypertension, rheumatoid arthritis, and coronary artery disease underwent preoperative cardiac evaluation prior to lung biopsy for a pulmonary nodule. Coronary angiography demonstrated a CTO of the mid left anterior descending artery (LAD) without other significant disease. Myocardial perfusion imaging revealed a large area of anteroseptal and apical ischemia. The patient was referred for CTO PCI.
Bilateral femoral arterial access was obtained with 8 French sheaths. The right coronary artery (RCA) was engaged with an 8 French JR 4 guide catheter and the left main coronary artery with an 8 French XB 3.5 guide catheter. Dual injection revealed a 30 mm long occlusion with calcification ( Fig. 1 A ). Antegrade wire escalation with a Fielder XT guidewire (Asahi Intecc) advanced through a Finecross microcatheter (Terumo) resulted in subintimal guidewire entry. A knuckle was formed with the Fielder XT guidewire to attempt subintimal guidewire crossing. The guidewire failed to advance through the occlusion, but could not be withdrawn into the microcatheter and upon further retrieval attempts it fractured, with the distal segment remaining embedded into the occlusion ( Fig. 1 B). The CTO was crossed with a parallel Pilot 200 guidewire (Abbott Vascular, Santa Clara, California, Fig. 1 C) and multiple balloon inflations were performed in an attempt to “free” the entrapped guidewire ( Fig. 1 D). Attempts were also made to push the guidewire fragment into the occlusion with a plan to cover it with a stent. Eventually, the Finecross catheter was removed together with the guidewire fragment ( Fig. 1 E). After implantation of three drug-eluting stents (2.25 × 30 mm, 2.5 × 30 mm, 2.75 × 30 mm), an excellent final result was achieved ( Fig. 1 F). The patient had an uneventful recovery.
3
Case 2
A 71-year-old man with a history of diabetes mellitus, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, cerebrovascular disease, and coronary artery disease with multiple prior PCIs developed unstable angina and was admitted for left heart catheterization.
Diagnostic angiography performed via right femoral access revealed 30% stenosis of the left main coronary artery, 50% stenosis of the mid LAD, 90% stenosis of the mid diagonal branch, and 80% stenosis of the mid RCA due to in-stent restenosis ( Fig. 2 A ). The RCA was engaged with a 6 French AL-1 guide catheter and the distal vessel was wired with a 0.014″ BMW guidewire (Abbott Vascular). The mid-RCA was dilated with a 3.0 × 15 balloon, but distal stent delivery failed in spite of using a guide catheter extension, and wire position was lost. Attempts to re-wire the RCA were challenging, and the distal radio-opaque tip of a 0.014″ Runthrough guidewire (Terumo, Warren, New Jersey) became entrapped in the proximal RCA stent ( Fig. 2 B).
Left femoral access was obtained and the RCA was engaged with a second 8 French guide catheter and rewired. A trapping balloon was used in the initial guide catheter to aid with removal of the entrapped guidewire, but during retrieval attempts the entrapped guidewire fractured with part of the wire extending outside the coronary ostium into the aortic root ( Fig. 2 C). Multiple retrieval attempts using various three-loop snares were unsuccessful. Emergent transthoracic and transesophageal echocardiography revealed the echo-dense wire protruding from the coronary cusp into the aortic root ( Fig. 2 D, E). Emergent surgery was performed with successful guidewire removal ( Fig. 2 F), followed by aortocoronary bypass graft surgery of the LAD, first diagonal, and right posterior descending artery. The patient had an uneventful postoperative course.
4
Discussion
Our cases demonstrate the potential adverse consequences and management of guidewire entrapment and fracture. If percutaneous retrieval fails, emergency surgery may be required to remove the entrapped guidewire and prevent subsequent adverse events.
In 1987, Hartzler et al. reported guidewire retention in 0.1–0.2% of 5400 consecutive cases . A more recent estimate of the incidence of guidewire entrapment among 2238 consecutive patients was 0.08% . We reviewed the published literature on guidewire-related complications since 2007 and identified 31 cases of wire entrapment ( Table 1 ) . Among these 31 cases, 5 (13.5%) were associated with CTO-PCI, 14 cases (45%) involved PCI of a bifurcation lesion, and a polymer-jacketed guidewire was implicated in 11 cases (35%). Karabulut et al. summarized lesion types at high risk for entrapment: bifurcations, tortuous and calcified lesions, CTOs, and in-stent restenotic lesions . The risk of wire unraveling and fracture increases with maneuvers where the wire is rotated more than 180 degrees , which has been proposed as a mechanism of fracture in two recently reported cases . However, techniques producing significant guidewire torquing may be unavoidable in PCI of CTOs and other complex lesions, for example when attempting to form a knuckle. Guidewire tips may get entrapped in the subintimal space or fold during advancement and retraction, and the distal segment of the wire may detach during retrieval attempts .
| Year | Author | Age/Sex | Vessel | Lesion and Approach Characteristics | Polymer-Jacketed Wire | Guidewire Complication | Management | Complications |
|---|---|---|---|---|---|---|---|---|
| 2015 | Tatli | 56 M | RCA | CTO, antegrade approach | No | Subintimal E + F | Conservative, jailed wire | None |
| 2015 | Park | 55 M | RCA | CTO, retrograde approach | Yes | E + F | Surgical | Pericardial perforation, tamponade |
| 2015 | Surhonne | 51 F | LAD | – | – | F | Percutaneous | None |
| 2014 | Alomari | 62 M | RCA | – | – | E + F in stent | Conservative | – |
| 2014 | Singh | 65 F | LAD | Calcified, distal CTO | – | E + F | Surgical + CABG | None |
| 2014 | Taniguchi | 72 M | LAD | Jailed wire at bifurcation | No | E in stent | Percutaneous | None |
| 2013 | Kim | 72 F | LM | – | No | F | Percutaneous, jailed wire | Subacute stent thrombosis, death |
| 2013 | Tamci | 73 F | LCX | Angulated, calcified | Yes | E + F in stent | Conservative, jailed wire | None |
| 2012 | Karabay | 67 F | IMA | – | Yes | E + F | Conservative, pericardiocentesis | Tamponade |
| 2012 | Sen | 68 F | LCX | Bifurcation | Yes | Kink + F | Conservative, jailed wire | None |
| 2012 | Ito | 85 F | RCA | Tortuous and calcified | Yes | E + F | Surgical + CABG | Pericardial and aortic perforation |
| 2012 | Al-Amri | 28 M | LAD | Jailed wire at bifurcation | – | E + F | Surgical + CABG | Stent thrombosis |
| 2011 | Sianos | 68 M | LAD | CTO, retrograde approach | Yes | E + F | Percutaneous | None |
| 2011 | Owens | 53 F | LAD | Jailed wire at bifurcation | Yes | E + F in stent | Percutaneous | None |
| 2011 | Modi | 77 M | LAD | Calcified, tortuous lesion | – | E + F in stent | Surgical + CABG | Angina 2 weeks later |
| 2011 | Pourmoghaddes | 65 M | LAD | Jailed wire at bifurcation | – | E + F | Conservative | None |
| 2010 | Armstrong | 61 M | RCA | Bifurcation, 99% occlusion | Yes | E + F | Percutaneous | None |
| 2010 | Burns | 64 M | LAD | Jailed wire at bifurcation | No | E + F in stent | Percutaneous | None |
| 2010 | Pawlowski | 71 M | LM | Jailed wire at bifurcation | Yes | Loss of HC | Percutaneous | None |
| 2010 | Karabulut | – | LCX | Tortuous and calcified | Yes | E + F | Conservative, jailed wire | None |
| 2010 | Karabulut | – | RCA | Bifurcation | Yes | Loss of HC | Conservative | None |
| 2010 | Karabulut | – | LCX | Tortuous and calcified | – | E + F | Conservative | None |
| 2010 | Kaplan | 56 M | RCA | – | – | E + F | Conservative | None |
| 2010 | Balbi | 46 F | LAD | Jailed wire at bifurcation | No | E + F | Surgical + CABG | None |
| 2008 | Demircan | 58 F | LCX | Bifurcation | No | Kink + F | Percutaneous | None |
| 2008 | Capuano | 63 M | LAD | Jailed wire at bifurcation | No | E | Surgical + CABG | None |
| 2007 | Kilic | 53 F | LCX | Tortuous | – | E + F | Conservative, jailed wire | AMI |
| 2007 | Dawarzah | 59 F | LCX | 99% stenosis | – | E + F in stent | Surgical + CABG | None |
| 2007 | Dawarzah | 60 M | LAD | Jailed wire at bifurcation | – | E + F | Surgical + CABG | AMI, death |
| 2007 | Cho | 75 F | LCX | Severely calcified, CTO at LAD | No | E | Percutaneous, later CABG | None |
| 2007 | Collins | 80 M | LAD | Bifurcation, distal CTO | No | E + F | Percutaneous | None |
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