Research
Letter
Retrieval
of
fractured
guide
wire
with
balloon
support
in
intermediate
coronary
artery:
A
rare
complication
and
management
Fractureofcoronaryguidewireduringpercutaneouscoronary interventionisaveryuncommoncomplication.1Guidewire
remnants may produce important consequences, such as
intracoronarythrombusformation,embolization,and perfo-ration.1,2Thereareafewtechniquesbeingrecommendedfor the treatment of fractured guide wire remnants. Here, we presentacasewherebywemanagedtoextractthecoronary guidewirefragmentinthearterywithballoonsupport.
A43-year-oldmalewithahistoryofsmoking, hypercho-lesterolemia,hypertension,andafamilyhistoryofcoronary artery disease was admitted with stable angina pectoris.
Electrocardiogram on admission showed normal sinus
rhythm with negative T waves in lead II, III, and a VF. ExercisetreadmilltestontheBruceprotocolrevealed2mm STdepressioninV4–V6atstage3.Leftventricularejection fractionwas 48% with the Simpson method.Angiography demonstratedasignificantproximalstenosisin left inter-mediate coronary artery (IMA) (Fig. 1A). Using a 7F extra backup (EBU, Medtronic, Inc., Minneapolis, USA) guiding catheter, a 0.014-inch hydrophilic guide wire (HI-TORQUE PILOT50®GuideWire,Abbott,USA)wasintroducedintothe IMAwith aballoon (2.015mmMaverick balloon,Boston Scientific, USA). The guide wire crossed the lesion sub-intimally andbecame trapped.The lesionwas difficult to cross.Duringthisstruggle,thedistalpartoftheguidewire becameinadvertently wedgedina smallsidebranch. The wiretipcouldnotbefreedandwithdrawalattemptsledto wire fracture. The distal fractured wire remained in the side branchandthe proximalfractured wirewas shaking in the IMA. A 1.51.5mm balloon (Maverick balloon, Boston Scientific, USA) was advanced over a second long
hydrophilic guidewire, andthenwasinflatedinthedistal partofthearterytowithdrawthefragmentofthewire.The fractured wire was wriggled out of the side branch and dropped in IMA. The distal 1.5cm remained in the IMA (Fig. 1B). The fractured wire was not withdrawn and a 2.015mmdistalballooninflationretrievalwasattempted. ThefracturedguidewirewaswithdrawnbycannulationEBU catheterintotheostiumofthe IMAandthe wirefragment was completely extracted outside through the catheter (Fig. 1C). The proximal lesion was successfully stented using 2.7532mm stent (Promus Element Plus) (Fig. 1D). Thepatientwas treatedwithintravenousheparin for48h anddischargedonaspirinandclopidogrel.Atthe6-month follow-up,thepatientwasfreeofsymptoms.
Thereareseveraltreatmentchoicesrecommendedforthe managementoffracturedguidewires,includingconservative treatment,loopsnareremoval,balloonangioplastyoverguide wire,two-orthree-wirerotation,stentingovertheretained wire, and surgery (Table 1). Interventional methodsand/or conservativetreatmentshouldbepreferredoverthesurgery formostofthecases.Ifentrappedguidewireremnantsare fragmentedandnonmetallicorlocalizedinthedistalpartof the vessels or chronically occluded vessels, they can be followed up conservatively. Another choice is leaving the guidewirefragmentwithinthecoronaryarterywithsystemic anticoagulation. Such fragments are less thrombogenic comparedwithmetallicpartsandcanbemobilizedordraw indianheartjournal68(2016) 361–363
Keywords:
Fracturedguidewire
Percutaneouscoronaryintervention Balloonsupport
Table1–Methodsforthemanagementoffracturedguide wires.
1.Conservativefollow-up 2.Interventionaltechniques
Extractionwithsnarecatheter Balloonangioplastyoverguidewire Stentingoverguidewire
Mobilizationandfixingintosmallsidebranch 3.Surgery
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theguidewiretoasidebranchwithitsslipperyproperties. Small and underinflated balloon catheters can beused for mobilization and dragging guide wire fragments into the lumenofasidebranch.Extractingtheguidewirewithasnare catheter can be used in proximal segment entrapment. If entrappedguidewiressticktostenoticlesionsandarefixedin thesurfaceoflesions,theyshouldbestented.Surgeryshould beconsideredifinterventionaltechniquesareunsuccessful,in thepresenceoflargerandlongerentrappedfragments,orif entrapment is within the left main coronary artery and accompaniedbymultivesseldisease.2–5
In our case, we first started with balloon support to withdrawthe fragmentofthe wireand managedtotakeit intothecatheter.Inconclusion,iftheguidewireentersasmall branchofanarteryand becomestrappedandfractured,an alternativefortheretrievalwithasnareorstentingistopass thelesionwithasecondguidewireandretrievetheretained filamentwithballoonsupport.
Conflicts
of
interest
Theauthorshavenonetodeclare.
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1. vanGaalWJ,PortoI,BanningAP.Guidewirefracturewith
retainedfilamentintheLADandaorta.IntJCardiol.2006;112:
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3. WoodfieldSL,LopezA,HeuserRR.Fractureofcoronary
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coatedcoronaryguidewiretips:whichformofmanagement
isbest?CardiolJ.2010;17:104–108.
BekirSerhatYildiz*
IsmailDoguKilic YusufIzzettinAlihanoglu PamukkaleUniversity,MedicalFaculty,DepartmentofCardiology, Denizli,Turkey Fig.1–Angiographydemonstratedasignificantproximalstenosisinleftintermediatecoronaryartery(A).Thedistal1.5cm remainedintheIMA(B)andthewirefragmentwascompletelyextractedoutsidethroughthecatheter(C).Theproximal lesionwassuccessfullystentedusingPromusElementPlus(D).
indianheart journal68(2016) 361–363
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HarunEvrengul Professor,PamukkaleUniversity,MedicalFaculty,Departmentof Cardiology,Denizli,Turkey *Correspondingauthor E-mailaddress:bserhatyildiz@yahoo.com(B.S.Yildiz)
Availableonline3March2016
http://dx.doi.org/10.1016/j.ihj.2016.02.012
0019-4832/ #2016CardiologicalSocietyofIndia.PublishedbyElsevierB.V. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
indianheart journal68(2016) 361–363
363
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