Percutaneous Evacuation of Detached Hydrophilic Coating of Jailed Guidewire

Case Report. A 71-year-old gentleman with a history of hypercholesterolemia and smoking was referred to our institution for primary intervention in ST elevation myocardial infarction (STEMI). He complained of typical chest pain lasting 7 hours and his echocardiogram showed ST elevation in inferior and posterior leads.

Vascular access was obtained through the right common femoral artery using 6 French (Fr) sheath. Coronary angiography revealed single-vessel disease with an acute proximal occlusion of the dominant circumflex artery. Distal flow was significantly reduced with estimated TIMI 1. The left main coronary artery (LMCA) was intubated with EBU 4.5, 6 Fr guiding catheter (Medtronic, Minneapolis, MN) and intracoronary injection of abciximab (ReoPro, Centocor, Malvern, PA) was given at the beginning of the procedure. A hydrophilic guidewire PT2 LS (Boston Scientific, Natick, MA) was advanced distally into the circumflex (CX) artery. The CX lesion was situated at the bifurcation with the large marginal branch OM1 (Medina 1,0,1). Another PT2 LS wire was placed in the obtuse marginal (OM)-1 branch to secure access to it. Successful manual thrombectomy was performed using the Export aspiration catheter (Medtronic). We decided to use the provisional stenting technique for this lesion. A cobalt-chromium stent Skylor 3.5 x 25 (Medtronic) was implanted, covering the orifice of the first marginal branch. Normal distal flow to both the CX and marginal branch was restored (TIMI 3). No significant plaque shift toward the OM1 branch was observed. Much effort was needed to remove the guidewire jailed in the marginal branch. In the control angiography, we noted a 4-cm long, thin structure (part of the guidewire) lying across the LMCA, extending from left anterior descending artery (LAD) toward the CX.

Both guidewires were removed and scrutinized. No obvious fragmentation or detachment of either of them was noted; they were of the same length, too. One of them, however, seemed to be lacking a few centimeters of its distal coating.

The decision was made to retrieve the lost fragment percutaneously. The guiding catheter reached well to the LMCA bifurcation, thus stabilizing the foreign body in situ. Initially, a loop was manually made at the end of the floppy HAAS guidewire (Carl Haas GmbH, Schramberg, Germany), but the removal attempt failed. Another floppy guidewire was inserted into the intermediate (ramus) branch with an intention to stabilize the foreign body. Another retrieval attempt proved unsuccessful and resulted in dislodgement to the distal LAD.

Two spiral-shaped, floppy non-hydrophilic guidewires (HAAS) were subsequently advanced into the distal LAD in the close proximity to the lost part of the wire. A torquer was used to wrap them around the foreign body. Both guidewires along with the trapped part of the wire entangled between them were removed as a single unit into the guiding catheter. The vascular sheath was removed a few hours after the procedure. Further hospitalization was uncomplicated. The patient was discharged to the referring hospital on the third day after the procedure.

Discussion. Percutaneous treatment of bifurcation lesions is associated with the increased risk of procedural complications, lesser primary efficacy and worse long-term prognosis compared to simple lesions. It is today's standard practice to place another wire into a considerably sized (> 2–2.5 mm) sidebranch when treating the bifurcation lesion. As a result the ostium and take-off of the sidebranch are modified and the risk of vessel closure reduced. If despite this measure such complication occurs, the jailed wire acts as a landmark and enables introduction of another wire through the stent struts into occluded side branch to optimize the result of angioplasty.^1,2 Prevention of side branch closure reduces the frequency of periprocedural myocardial infarction in elective PCI. It may be speculated that in patients with acute coronary syndromes, such treatment increases the amount of reperfused myocardium.³ There are no data on the long-term effects of the trauma to the ostium of a side branch induced by the removal of a jailed wire.

Detachment of the distal part of a jailed guidewire is a rare complication. In our laboratory, this is the first case in a series of 8,000 PCIs performed. Delgado reported two such instances in 1,000 consecutive PCIs (they were not only jailed wires). In the material of 5,400 angioplasty procedures analyzed by Hartzler, only 8 were complicated by parts of a guidewire being left in the coronary bed during its removal. Only 4 such cases were reported by Louvard in his material of a few hundred bifurcation PCIs — all of them associated with hydrophilic wires.^2,4,5 According to the authors the risk of this complication is less if the side branch wire is removed before high-pressure balloon postdilatations are performed (stent/vessel ratio 0.9–1.0). It has been emphasized that the removal of a jailed wire may induce a proximal vessel dissection by the uncontrolled forward movement of the guiding catheter.

The situation where the hydrophilic coating of a jailed wire is peeled off is unique.^6,7 Modern guidewire constructions are considered safe in the treatment of bifurcation lesions with jailed wire technique. The risk factors are: utilizing hydrophilic wires, high-pressure stent implantations (>12 atm), treatment of the in-stent restenosis with another stent implantation, as well as covering long stretch of a jailed wire with a stent.^8,9 Jailed wire removal may be additionally hampered by the presence of calcifications and severe tortuousity of the side branch, especially when elephant's leg phenomenon (concertina effect) occurs.¹⁰

Percutaneous retrieval of lost foreign bodies is regarded standard technique in the management of such complications.¹¹ There are many devices utilized in such instances: pigtail catheters, Dotter's basket, Goose-neck snare loop or retrievers, biopsy forceps, Tornus catheter, balloon catheter and manually pre-shaped guidewires.^10,12–18 An interesting innovation in this field may be considered a new micro-snare with ultra-small profile (0.014 inch) called the Radius MICRO^™ Elite Snare (Radius Medical Technologies, Inc., Acton, MA). Its unique construction combining high torquability and maneuverability enables easier delivery through both diagnostic and therapeutic catheters to distal targets. In the past, namely in the 80s and 90s, urgent bypass surgery combined with foreign body removal was considered the treatment of choice. Another option was to leave the lost portion of a wire in situ and cover it with a stent.^4,19–24 Even today, when the risk of the retrieval attempt is considered prohibitive and the chance of success is poor, operators may choose this treatment option. If the foreign body is left in a coronary artery, double antiplatelet therapy or oral anticoagulation is recommended, usually without complications.^7,25

The spectrum of devices used for foreign body retrieval from the coronary tree is limited by space constraint and the risk of vessel damage. In the presented case, percutaneous evacuation was considered the treatment of choice as the patient had an acute coronary syndrome and had been administered IIb/IIIa inhibitor.

Deep intubation of the guiding catheter stabilized the foreign body in the distal LMCA, and thus lessened the risk of embolization to the aorta and its branches, including the brain arteries. The very fact that the retained fragment was situated in close proximity to the guiding catheter made retrieval with biopsy forceps a tempting option. Yet the associated risk of vessel damage, especially in the LMCA, was considered too high. Alternatively, the Amplatz gooseneck snare (Microvena, White Bear Lake, MN) could have been utilized by deploying it down into the circumflex artery in an attempt to catch the wire fragment while moving the device upward. The operator decided to use manually loop-shaped non-hydrophilic guidewire. This attempt failed and was complicated by dislodgement into the distal LAD. The only option left was to advance two spirally pre-shaped wires down the LAD next to the lost fragment and twist them around it, which proved successful. The technique recommended for the retrieval of lost stents is similar.¹³ We have found a report of the retrieval of the broken wire fragment by using three guidewires twisted together.²⁶ In that case, a similar attempt to retrieve a foreign body with a single wire also proved impossible. We therefore assume single-wire retrieval is unlikely to succeed and should not be attempted. Using more than one wire provides more stability and significantly increases the chances to retrieve the lost fragment in an uncomplicated fashion.

Conclusion. Detachment of the hydrophilic coating is a very rare complication of PCI performed utilizing the jailed wire technique. Percutaneous evacuation of the foreign body is an effective and safe therapeutic option. In each case, the risk associated with the removal (vessel dissection, abrupt closure and systemic embolism) should be weighted against estimated risk of leaving it behind in the coronary artery (thrombosis, distal embolization, stenosis and occlusion). When the percutaneous retrieval attempt proves impossible or the risk of leaving it is prohibitive, surgical intervention should be considered.

References

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