Abstract
The fracture of IVUS catheter tip in the coronary artery is a very rare complication. It should be removed as soon as possible. Although it seems to be easy at first glance, percutaneous retrieval of broken IVUS catheter tip has some challenges. We hereby present a case report of successful percutaneous retrieval of broken IVUS catheter, probably caused by calcific left main stenosis, from the left circumflex artery using loop snare technique.
1
Introduction
Intravascular foreign bodies are thrombogenic and may result in adverse events such as acute myocardial infarction, especially left in the coronary artery. Thus, intravascular foreign bodies should be removed percutaneously or surgically as soon as possible. If it is not possible, deployment of the foreign bodies, especially those with small size such as stents and small pieces of wire segments, with a balloon or crushing technique may be an alternative to retrieval . Percutaneous retrieval of intravascular foreign bodies has been used as a common and safe procedure. Although percutaneous retrieval of fractured catheter and guidewire, fractured Rotafloppy wire, migrated stents and misplaced coils has been reported, the number of case reports describing the percutaneous retrieval of broken intravascular ultrasound (IVUS) catheter tip in the coronary artery is very limited. We present a challenging complication case of a broken IVUS catheter tip in the coronary artery. Also, we tried to explain our experience with successful percutaneous retrieval of this broken IVUS catheter tip using loop snare technique.
2
Case report
A 74-year-old man without a history of cardiovascular disease was admitted to our hospital because of typical chest pain. His treadmill exercise test was positive and elective coronary angiography (CAG) was performed. CAG revealed an intermediate calcific stenosis (approximately 50%) at the ostial segment of left main coronary artery (LMCA) without any significant stenosis in other coronary arteries ( Fig. 1 A ). Subsequently, IVUS examination was performed to detect whether this stenosis was significantly stenotic or not. A 7F Judkins left (JL) 4.0 guiding catheter was engaged in the LMCA, and a 0.014” floppy wire (Asahi, Intecc Co. Japan) was inserted distally into the left circumflex artery (LCX). IVUS catheter (40 MHz Atlantis SR Pro2, Boston Scientific, USA) was advanced over the floppy wire up to the mid segment of LCX and IVUS examination was performed from distal to proximal direction including LMCA with automatic pull-back device (0.5 mm/s). IVUS examination revealed that the stenosis in the LMCA was significant and surgery decision was made.
After the IVUS examination, we recognized that the distal tip of the IVUS catheter was broken off and the distal part including the radiopaque marker remained in the LCX. Because of the risk of its thrombogenicity, we decided to retrieve the broken IVUS catheter tip as soon as possible. Initially, we advanced two more 0.014” floppy wires alongside the previous IVUS wire. First, we clamped all 3 wires using the whirled wires technique with rotation. Second, we began to retract the broken IVUS catheter tip with the aid of cramped wires, but we did not succeed. Thereupon, a 2.5 mm balloon angioplasty catheter was advanced over a second wire distally to the broken IVUS catheter tip and the balloon angioplasty catheter was pulled from distal to proximal direction with low pressure dilatation. Probably because of the mildly ectatic segment of the LCX, broken IVUS catheter tip got rid of balloon angioplasty catheter after every attempt. A bigger size of balloon angioplasty catheter could not be used because of the presence of significant stenotic lesion in the LMCA. Lastly, we decided to retrieve the broken IVUS catheter tip with a loop snare. The stenotic lesion at the ostial segment of LMCA was crossed with a microcatheter with a 2-mm loop snare (Amplatz Goose Neck Snare kit, USA) successfully but hardly. The snare was then advanced distally through the LCX. We tried to catch the broken tip by pulling the loop snare from distal to proximal direction ( Fig. 1B and 1 C). After several attempts, loop snare caught the broken IVUS catheter tip from its distal part and we achieved to retrieve this broken IVUS catheter tip into the guiding catheter successfully ( Fig. 1C, 1D and 1 E). After retrieval, we compared the normal and broken IVUS catheter and noticed that the broken catheter tip appeared quite long ( Fig. 2A and 2 B ).
2
Case report
A 74-year-old man without a history of cardiovascular disease was admitted to our hospital because of typical chest pain. His treadmill exercise test was positive and elective coronary angiography (CAG) was performed. CAG revealed an intermediate calcific stenosis (approximately 50%) at the ostial segment of left main coronary artery (LMCA) without any significant stenosis in other coronary arteries ( Fig. 1 A ). Subsequently, IVUS examination was performed to detect whether this stenosis was significantly stenotic or not. A 7F Judkins left (JL) 4.0 guiding catheter was engaged in the LMCA, and a 0.014” floppy wire (Asahi, Intecc Co. Japan) was inserted distally into the left circumflex artery (LCX). IVUS catheter (40 MHz Atlantis SR Pro2, Boston Scientific, USA) was advanced over the floppy wire up to the mid segment of LCX and IVUS examination was performed from distal to proximal direction including LMCA with automatic pull-back device (0.5 mm/s). IVUS examination revealed that the stenosis in the LMCA was significant and surgery decision was made.
