|Year : 2017 | Volume
| Issue : 1 | Page : 47-50
Coronary balloon-assisted retrieval of a broken coronary guidewire
Sheshagiri Rao Damara, Ramachandra Barik, Akula Siva Prasad
Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||10-Mar-2017|
Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telengana
Source of Support: None, Conflict of Interest: None
Guidewire fracture is more frequent during angioplasty of chronic total occlusion (CTO) of coronary artery though it is an infrequent complication in routine percutaneous coronary intervention. The percutaneous retrieval techniques such as balloon-assisted technique, wire intertwining method, triple wire technique, use of micro snare, stent to crush the wire, and conservative management are various methods which are used with various degrees of success. The surgical retrieval is almost a bail out option. In this case report, we illustrate a case of successful noncompliant coronary balloon-assisted retrieval of a broken piece of a coronary CTO guidewire.
Keywords: Broken coronary guidewire, chronic total occlusion, coronary angioplasty, percutaneous retrieval
|How to cite this article:|
Damara SR, Barik R, Prasad AS. Coronary balloon-assisted retrieval of a broken coronary guidewire. Nig J Cardiol 2017;14:47-50
| Introduction|| |
The incidence of coronary guide wire fracture is 0.2%–0.8%. Coronary guidewire breaks during angioplasty due to entrapment in tight and tortuous lesion, crushed or caught in stent struts, wire cutting by rotational atherectomy devices, loss of structural integrity, and when used in chronic total occlusion (CTO)., The broken part can be retrieved by snare, wire intertwining, balloon support, mobilizing, and pressing the broken fragment to the wall of the distal part of the artery, triple wire technique or leave the wire alone if it is in an insignificant size distal vessel or branch.,,,, The retrieval by surgery is the last option. However, the various retrieval techniques and their relative success rates are purely based on consensus.
| Case Report|| |
A 58-year-old hypertensive male smoker presented with dyspnea on exertion NYHA III over the past 3 months. He had anterior wall myocardial infarction (AWMI) 1 year back which was treated by thrombolysis. Twelve-lead electrocardiogram was suggestive of evolved AWMI. There was moderate left ventricular dysfunction with septal and anterior wall hypokinesia. Angiography was performed through right radial access. The left anterior descending coronary artery (LAD) had proximal total occlusion with reasonable stump [Figure 1]. The same was filling through homo and contralateral Rentrop's Grade II collaterals. The dominant right coronary artery and left circumflex artery had mild disease. Elective angioplasty of CTO of LAD was planned with informed consent as he was not willing to undergo coronary artery bypass graft (CABG) as a first option. We chose antegrade approach as there were no suitable contralateral collaterals. A 7 Fr extra backup guiding catheter (Cordis Corp., Florida, USA) was used to cannulate the left coronary artery from right transfemoral approach. A bolus dose (5000 IU) of unfractionated heparin was given. ASAHI Fielder XT (Asahi Intec) failed to cross on several attempts. Then, this wire was replaced by ASAHI Gaia Second (ASAHI Intec. Co., Ltd]. We suddenly felt the given away of the guidewire. Fluoroscopy in different projections concluded that guide wire had broken. The tip of the guidewire was still in LAD [Figure 2]. It's aortic end was still inside the guide catheter which corresponds to middle part of aortic arch [Figure 2]. The guide catheter was in hooking position in the left main coronary artery. We planned to retrieve it by balloon technique. The proximal segment (the segment with the primary operator was removed). A ChoICE Extra Support [Boston Scientific] wire was used to wire ramus intermedius artery. The aortic end of the broken wire slipped further toward ascending aorta and the coronary end appeared more redundant and slipped into the left circumflex artery [Figure 3]. We took a 2.5 mm × 12 mm noncompliant balloon because the guide catheter was 7 F which has an internal lumen diameter of 2.01 mm. The balloon was inflated at the level of ascending aorta up to 14 atmospheric pressure to fix the distal end of broken guidewire to the lumen of guide catheter. Then, the entire system was tried to pull out slowly. However, on pulling the guiding catheter out, the broken guidewire started slipping from guide catheter. The balloon in the guide was deflated completely and the indiflator was maintained at negative pressure. We forwarded the guide catheter to aortic root. The balloon was inflated up to 18 ATM keeping 50% of the balloon beyond the tip of the guide catheter [Figure 4]. The entire system was pulled out slowly to the tip of the 7 Fr femoral sheath in the groin [Figure 5]. Then, balloon was deflated and pulled into guide and re-inflated. 7 Fr sheath, guide catheter, the broken wire, and intact guidewire were safely externalized with firm pressure in the puncture site. This patient was advised elective CABG.
|Figure 1: Angiography in the left anterior oblique-caudal view demonstrated a significant proximal stenosis in the left anterior descending coronary artery followed by chronic total occlusion after the first diagonal branch|
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|Figure 2: Fluoroscopy in RAO-Caudal (17 and 36°) showed the coronary end of guidewire is still in the left anterior descending coronary artery (A), the broken end of the guidewire was in the middle of the aortic arch (B) but inside the guide catheter (C)|
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|Figure 3: A ChoICE Extra Support [Boston Scientific] wire was was used to wire ramus intermedius artery (A).The broken guidewire (B and C) slipped further towards coronary artery when a 2nd guidewire was introduced to wire ramus intermedius|
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|Figure 4: The noncompliant was inflated up to 18 ATM to fix the broken part of guidewire to the the inner wall of guide catheter. Most part of the balloon was kept outside the catheter for giving maximum support to prevent slippage of broken guide wire. A, B, C, and D are broken wire, 2nd percutaneous coronary angioplasty wire, inflated noncompliant balloon, and guide catheter, respectively|
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|Figure 5: The entire assembly in Figure 4 has been pulled down under fluoroscopy to groin|
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The entire length of 190 cm of broken guidewire examined externally. A detail description of this broken guidewire has been mentioned in [Figure 6].
|Figure 6: The zoom view of the uncoiled spring of the last 15 cm of guide wire|
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| Discussion|| |
The possible reason for the breakage of guidewire may be due to CTO with extremely hard and fibrotic plaque and excessive torque.,, In the present case, the best approach of management was to remove the broken part of the guidewire because it had a significant length extending into coronary artery and aorta which may lead to thromboembolic complication. We feel the balloon-assisted approach using a relatively smaller noncompliant balloon was a good decision. As we reported above, even simple retrograde push of another guidewire pushed the broken guide wire more distally. Therefore, a longer balloon could have pushed the broken part of guidewire out of guide catheter. A half protruded noncompliant balloon further supported the fixation. In this situation, a gentle movement and a watchful observation under fluoroscopy are must. A higher level of actual clotting time is quite helpful as broken guidewire is highly thrombogenic.
| Conclusion|| |
Percutaneous coronary interventions of chronic total occlusion are not without complications. Dissection, perforation, thrombosis of coronary artery, thromboembolism, contrast-induced nephropathy and breakage of coronary guidewire are the well-known complications in this situation. Hardware breakage inside the intravascular compartment poses a unique challenge. In the present case, we successfully retrieved the broken piece of guidewire using a noncompliant balloon which we inflated at the distal tip of guide catheter with half of balloon protruded out. We believe this modified technique is quite easy if the operator does not have a longer balloon in the shelf or the operator fears that a long balloon may further push the broken piece of guidewire out of the guide catheter.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]