Abstract
In contemporary practice, entrapped devices are rarely encountered during percutaneous coronary intervention (PCI) but can be associated with serious morbidity and mortality. We present a case of a 62 y/o male who presented with an acute coronary syndrome. Revascularization was performed and complicated by guide wire entrapment and fracture. Cardiologists should be aware of this complication and the treatment options available.
1
Case report
A 62 y/o man with a history of hypertension and ongoing tobacco use presented to the emergency room with 2 weeks of intermittent and progressive weakness, near syncope and anginal quality chest discomfort. Initial ECG demonstrated sinus rhythm with complete heart block and a wide QRS ventricular rate of 41 bpm. There was evidence of ST segment elevation in the inferior leads concerning for an inferior ST elevation myocardial infarction (STEMI). The patient was taken emergently to the catheterization lab after receiving oral aspirin 325 mg, clopidogrel 600 mg and 5000 unit IV heparin bolus. A temporary pacing wire was placed in the right ventricle via 6 F femoral vein approach. Coronary angiography revealed a 100% thrombotic occlusion of the proximal RCA with non-obstructive disease in the left coronary system and no evidence of left to right collateral flow ( Fig. 1 ). Given ongoing chest pain with complete heart block, the decision was made to pursue primary percutaneous coronary intervention (PCI).
A 6 F JR4 (Medtronic) guide was used via the right femoral artery approach for intervention. The lesion was crossed without difficulty using an Abbott vascular ASAHI prowater 0.014”/180 cm wire. After several balloon inflations in the proximal to mid RCA using an Emerge Monorail 2.5 mm × 15 mm (Boston Scientific) balloon, there was evidence of diffuse disease extending from proximal to the distal segment of the RCA. TIMI III flow was achieved with placement of three overlapping drug eluting stents (Xience Xpedition, Abott Vascular Santa Clara, CA). Two stents were placed in the mid to distal RCA (2.5 × 28 mm, 2.5 × 28 mm) in an overlapping fashion. Stents were deployed at 14 atm. Intra vascular ultrasound (IVUS) (Eagle eye platinum coronary imaging catheter, Volcano Therapeutics Coyol Alajuela, Costa Rica) was then performed to evaluate a hazy area in the proximal RCA. There was some difficulty passing the IVUS catheter into the mid RCA over the proximal stent edge in the mid RCA but we were able to use IVUS to confirm the presence of severe plaque proximal to the stented segment in the mid RCA. The decision was made to place an additional stent (third) in the proximal RCA. ( Fig. 2 ). Attempts at passing a 3.5 × 15 mm DES was difficult with similar resistance which was encountered with the IVUS catheter at the proximal edge of the stent in the mid RCA. Attempts at placing the stent did result in movement of the distal portion of the coronary wire although wire position was never completely lost in the RCA. Eventually, the stent was positioned in the proximal RCA overlapping with the stent in mid RCA. The stent was deployed at 14 atm and the stent balloon was re-inflated at the stent overlap site at 14 atm. The stent balloon was removed without difficulty but we were unable to remove the guidewire. The guide wire appeared entrapped between stents in the proximal and mid RCA. Attempts at removing the guidewire resulted in sheering of an approximate 8-10 cm portion of the wire including the radio-opaque portion of the wire ( Figs. 3 and 4 ). The proximal end of the sheered wire extended into the right coronary cusp of the aorta (3-4 cm). The patient remained hemodynamically stable with TIMI 3 flow. The decision was made to abort the case and discuss further management options.
The patient was transferred to the Medical Intensive care unit on triple anti-platelet therapy (ASA, plavix and integrillin). He did require transient pressor support for presumed right ventricular infarct and on day three he was weaned off pressor support with recovery of sinus node function. The patient did undergo follow-up angiography prior to discharge which showed a patent RCA with TIMI 3 flow and coronary wire unchanged in position from prior cath. After discussing risks and benefits of removal of the wire, either surgically or percutaneously versus conservative management, a decision was made to manage conservatively. The patient was discharged home on day ten on dual antiplatelet therapy.
2
Discussion
In contemporary practice, entrapped devices including catheters, balloons and guidewires, are rarely encountered during PCI but can be associated with serious morbidity and mortality . The possible complications of retained devices include thrombosis, embolization, sepsis, vessel dissection, and perforation. There are limited data to guide management of retained devices. This review summarizes existing literature on management and outcomes related to entrapped devices during PCI.
Over the last two decades, several case reports and small case series have described management and outcomes in patients with entrapped devices ( Table 1 ). Consideration is given to surgical or percutaneous removal of the device versus leaving the device in situ . Factors such as type of device retained, risk of retrieval, risk of retention, clinical stability and anatomy all come into play when considering the best short and long term outcome.
| Study | Wire/device Name | Site of trapping | Mechanism of trapping | Length | Treatment | Success | Complications |
|---|---|---|---|---|---|---|---|
| Hatzler | Gold floppy (2) Flexible/Steerable High Torque LPS guidewire ⁎ (3) Microbore-I Gold Band | Mid RCA(1) Distal LCX(1) RCA LCX LCX(2), LAD(1) LCX Distal LCX | Torque & withdrawing N/A N/A N/A Extreme torquing Lateral stress | > 20 cm 5 cm 2 cm 1 cm 3 cm | Pigtail catheter Left Amplatz Balloon withdrawal Conservative Conservative Balloon withdrawl Conservative | Yes Yes No N/A N/A Yes N/A- | No Embolized ⁎⁎ No No No No No |
| Alexio | Guide wires Rotoblator Stents | LAD(2), RCA(1) RCA(2) LAD(3) Ramus(1) | N/A | N/A | Surgical Removal | Yes | No |
| Modi | Guidewire | LAD extending in to the aorta | N/A | N/A | Surgical Removal | Yes | None |
| Al-Amri | Guidewire | LAD extending in to the aorta | Entrapped in stent struts | N/A | Surgery | Yes | No (6 months) |
| Hong | BMW Guidewire | LAD | N/A | N/A | Snare Conservative | No | No (12 months) |
| Gaal | Guidant Guidewire | LAD | Entrapped in the lesion | N/A | Snare Conservative | No | No (8 months) |
| Kaplan | Guidwire | RCA | Excessive tensile force or entrapment by stent struts | 1.5-2 cm | N/A | N/A | No (2 years) |
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