Abstract
Introduction
The presence of symptomatic or asymptomatic intravascular/intracardiac foreign body (FB) is underreported in the literature, but it is more commonly encountered in clinical practice. Nowadays, losing a coronary stent or a guidewire has become a rare event. However, due to the constant increase in the total number of worldwide performed coronary interventions (PCI) and especially due to an increase also in the technical difficulties of these procedures (i.e., new devices+complex techniques), this kind of “lost FB complication” may again become clinically relevant.
Case reports
We report two cases where, during challenging PCIs, 0.014-in. guidewires broke, remaining firmly anchored in the coronary tree floating with their proximal part in the aorta. These wires could have been successfully retrieved with a dedicated three-dimensional snare device, which is specifically manufactured for facilitating this kind of retrieval interventions.
Conclusions
Intracoronary lost guidewires, if untreated, may lead to serious cardiovascular complications, suggesting that one should attempt every possible maneuver to retrieve them from the coronary circulation. By describing the peculiarity of the Entrio snare device, we finally suggest that this kind of dedicated three-dimensional snare device is an excellent tool at cardiologists’ disposal for retrieving intracardiac and intravascular lost wires.
1
Introduction
It is more than 60 years that physicians are confronted with the presence of intravascular/intracardiac foreign bodies (FBs), which, at that era, could only be retrieved by a surgical approach. It is only since the mid 60s that an efficacious and less invasive endovascular retrieval alternative appeared . Many retrieval techniques are already described in the literature: loop snare, dormia basket, hocked guide wire or catheter, Fogarty balloon, bronchoscopic forceps, and cardiac biotome. However, none of these techniques have emerged as the best retrieval modality to safely, rapidly, and successfully retrieve lost FBs . Intracoronary lost FBs, especially stents, are usually retrieved with a small balloon inflated distally the FB and gently pulled back in order to anchor the FB and retrieve it in the guiding catheter. If this maneuver is unsuccessful, sometimes, the lost FB has to be left in the coronary tree and fixed with the implantation of a stent aimed to jail the FB between the stent struts and the coronary wall .
In the presence of an intravascular/intracardiac FB, before starting to discuss the best retrieval methodology, one should be aware of the fact that the natural history of an asymptomatic intravascular/intracardiac FB is presently unclear and that a large spectrum of FB related complications has already been reported . Interestingly, if the FB is located in the coronary circulation, outcomes are in many cases poor . In the mid 90s, a lot of interest was given to the lost-coronary stent phenomenon, because at the very early beginning of the stent era, this phenomenon was quite frequently observed by interventionists (up to 1% of all implanted stents) .
We report two cases where, during challenging percutaneous coronary interventions (PCIs), a long segment of a 0.014-in. guidewire broke and remained fixed in the coronary tree partially also floating in the aorta. Both guidewires could have been successfully retrieved with a dedicated three-dimensional snare device, which is specifically built for facilitating this kind of vascular retrieval interventions.
2
Patient 1
An 81-year-old patient was referred to our tertiary heart center for an elective PCI of the right coronary artery (RCA), which was chronically occluded from its ostium since almost 18 months ( Fig. 1 A ). Despite medical treatment, the patient suffered from life-limiting dyspnea, interpreted as angina equivalent (CCS 2-3), and posterior ischemia on myocardial scintigraphy. The left ventricular ejection fraction was mildly depressed (50%). The scheduled RCA recanalization was attempted through a 6F left Amplatz 1 guiding catheter in order to get enough support and push ability also with stiff guidewires. At the beginning, a 0.014-in. Cross-it 200 guidewire (Abbott Vasc., Abbott Park, IL, USA) was utilized to test the occlusion resistance. After a few minutes of trying to find and track a microchannel through the occlusion, we decided to try a stiffer wire. By pulling back the Cross-it wire, we immediately noticed that we could not correctly retrieve it into the guiding catheter. Finally, by pulling hard, the wire broke remaining with an anchored part in the proximal part of the RCA and a floating part in the ascending aorta ( Fig. 1 B). At this moment, using the same 6F guiding catheter, we utilized a 9–15-mm self-sizing Entrio snare (Bard, Murray Hill, NJ, USA) in order to snare the lost wire and retrieve it into the guiding catheter. Snaring the wire was immediately achieved ( Fig. 2 A and B); however, for several times during the retrieval manoeuvre, the wire slipped out of the snaring system probably because it was too firmly fixed in the RCA ostial wall. To finally succeed in our retrieval procedure, we decided to snare and retrieve the wire only for few centimetres into the guiding catheter and then to jail it there with a balloon expandable stent (Liberte’ Stent 2.5/20 mm, Boston Scientific, Natick, MA, USA). The guiding catheter containing the jailed wire, the implanted stent and the balloon still inflated, could finally be retrieved outside the femoral sheath ( Fig. 3 A and B). The PCI was then aborted and the patient sent home on improved medical treatment.
2
Patient 1
An 81-year-old patient was referred to our tertiary heart center for an elective PCI of the right coronary artery (RCA), which was chronically occluded from its ostium since almost 18 months ( Fig. 1 A ). Despite medical treatment, the patient suffered from life-limiting dyspnea, interpreted as angina equivalent (CCS 2-3), and posterior ischemia on myocardial scintigraphy. The left ventricular ejection fraction was mildly depressed (50%). The scheduled RCA recanalization was attempted through a 6F left Amplatz 1 guiding catheter in order to get enough support and push ability also with stiff guidewires. At the beginning, a 0.014-in. Cross-it 200 guidewire (Abbott Vasc., Abbott Park, IL, USA) was utilized to test the occlusion resistance. After a few minutes of trying to find and track a microchannel through the occlusion, we decided to try a stiffer wire. By pulling back the Cross-it wire, we immediately noticed that we could not correctly retrieve it into the guiding catheter. Finally, by pulling hard, the wire broke remaining with an anchored part in the proximal part of the RCA and a floating part in the ascending aorta ( Fig. 1 B). At this moment, using the same 6F guiding catheter, we utilized a 9–15-mm self-sizing Entrio snare (Bard, Murray Hill, NJ, USA) in order to snare the lost wire and retrieve it into the guiding catheter. Snaring the wire was immediately achieved ( Fig. 2 A and B); however, for several times during the retrieval manoeuvre, the wire slipped out of the snaring system probably because it was too firmly fixed in the RCA ostial wall. To finally succeed in our retrieval procedure, we decided to snare and retrieve the wire only for few centimetres into the guiding catheter and then to jail it there with a balloon expandable stent (Liberte’ Stent 2.5/20 mm, Boston Scientific, Natick, MA, USA). The guiding catheter containing the jailed wire, the implanted stent and the balloon still inflated, could finally be retrieved outside the femoral sheath ( Fig. 3 A and B). The PCI was then aborted and the patient sent home on improved medical treatment.
