Kaohsiung Medical University Institutional Repository:Item 310902000/11429

Kaohsiung J Med Sci March 2009 • Vol 25 • No 3 151 Coronary artery disease is one of the leading causes

of death in Taiwan and its prevalence has increased in recent decades [1]. The management of significant coro-nary artery disease includes percutaneous transluminal coronary angioplasty (PTCA) and stent implantation in additional to conventional medical therapy and surgery. Complications of PTCA include myocardial infarction, cerebrovascular accident, arrhythmia, vas-cular complications, contrast reaction and mortality [2]. Entrapped devices, including catheters, balloons and guidewires, are rarely encountered but these may cause serious complications [3–5]. We present the case of a man who received PTCA that was complicated with a retained broken guidewire fragment in the right

coronary artery (RCA). We discuss the treatment strat-egy along with the previous literature.

C

P

An 85-year-old man had a history of diabetes mellitus, chronic kidney disease and benign prostate hyperpla-sia. He suffered from sudden onset chest pain and dys-pnea. The characteristics of chest pain were oppressive sensation over the lower sternum, without radiation, and lasting for more than 30 minutes. He was sent to the emergency room after one episode of syncope. At the emergency room, initial vital signs showed his blood pressure was 121/78 mmHg, pulse rate was 70 beats/ min, respiratory rate was 18 breaths/min and body temperature was 36.5°C. Chest auscultation revealed bilateral basal crackles and a regular heart sound with-out cardiac murmur or S3 gallop.

Serial 12-lead electrocardiography showed atrial fibrillation with a rapid ventricular rate and T wave inversion in leads III, aVF, V3 and V4. Chest X-ray Received: Feb 12, 2007 Accepted: Mar 3, 2009

Address correspondence and reprint requests to: Dr Tsung-Hsien Lin, Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Tzyou 1st_Road,

Kaohsiung 807, Taiwan. E-mail: [email protected]

M

ANAGEMENT OF A

R

ETAINED

C

ORONARY

G

UIDEWIRE

F

RAGMENT

D

URING

P

ERCUTANEOUS

T

RANSLUMINAL

C

ORONARY

A

NGIOPLASTY

:

A C

ASE

R

EPORT

Chun-Yuan Chu,1_{Tsung-Hsien Lin,}1,2_{Ho-Ming Su,}1_{Wen-Chol Voon,}1,2

Wen-Ter Lai,1,2_{and Sheng-Hsiung Sheu}1,2

1_{Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University} Hospital, and 2_{Department of Internal Medicine, Faculty of Medicine, College of Medicine,}

Kaohsiung Medical University, Kaohsiung, Taiwan.

Retained fractured guidewire fragments are rarely encountered during percutaneous coronary intervention, but may cause serious morbidity. We present the case of an 85-year-old man who suf-fered from this complication. He was successfully treated by coronary stent without peri-procedure complications. Follow-up coronary angiography revealed no in-stent restenosis. Coronary interven-tionists should know how to manage this complication.

Key Words:coronary angioplasty, fractured guidewire, retained foreign body, retained guidewire, stent

C.Y. Chu, T.H. Lin, H.M. Su, et al

revealed cardiomegaly and mild pulmonary conges-tion. Cardiac enzymes were elevated (peak values: CK, 560 U/L; CK-MB, 27.9 U/L; troponin I, 10.58 ng/mL). Non-ST segment elevation myocardial infarction was considered and heparinization was prescribed with oral aspirin and clopidogrel.

Early invasive strategy was favored because of ele-vated cardiac markers, and coronary angiography was performed. Right coronary angiography revealed 90% eccentric stenosis in segment 1–2 and 75% eccentric stenosis from the distal segment 3 to the posterior de-scending artery (PDA) (Figure A). Left coronary an-giography revealed normal left main coronary artery, 50% concentric stenosis in the diagonal branch of the left anterior descending artery, and 90% eccentric ste-nosis in the obtuse marginal branch 1 (OM1) of the left circumflex artery (LCX) (Figure B). PTCA was arranged for the RCA and LCX lesions.

For PTCA in RCA, the proximal stenotic lesion was inflated initially with a 3.0× 20-mm balloon after

passing a floppy wire to the PDA. Because the 2.0 ×20-mm balloon was unable to cross the distal RCA lesion, another wire was used as the buddy wire to facilitate balloon passage. After successful ballooning of the dis-tal RCA lesion, we tried to negotiate the passage of the second wire to the posterolateral (PL) branch in preparation for treating the distal RCA bifurcation lesion. However, the second wire did not pass into the PL branch. Therefore, we chose another hydrophilic wire but some resistance was found when this guide-wire was advanced in the guiding catheter. Because the wire could not be moved further, we removed the wire and found that the tip was damaged, but we failed to notice that another broken wire tip was retained in the guiding catheter. Later, we placed another wire in the PL branch successfully. The broken tip was pushed into the proximal RCA when we advanced the bal-loon catheter (Figure C). We tried to retrieve the broken guidewire using a snare, but unsuccessfully. Thereafter, we decided to push the broken guidewire as distally

A B C

E F

D

Figure.Coronary angiography. (A) Anteroposterior cranial view (AP0 CRA30) of the right coronary artery (RCA). (B) Right anterior oblique caudal view (RAO30, CAU20) of the left anterior descending artery. (C) Broken guidewire tip in the proximal RCA. (D) Broken guidewire tip located in the middle part of the Micro-Driver stent over the distal RCA. (E) After stent deployment. (F) No significant in-stent stenosis 3 months later.

as possible with the balloon. The broken guidewire was finally advanced to the PDA. A Medtronic Micro-Driver coronary stent (2.75× 18 mm; Medtronic Inc., Minneapolis, MN, USA) was successfully crossed with the broken guidewire, which was located in the middle part of the stent (Figure D). The stent was deployed at 9 atmospheres for 20 seconds. Final angiography showed 15% residual stenosis (Figure E). We found no evidence of coronary artery dissection or perforation. The proximal RCA and LCX OM₁ branch were suc-cessfully implanted with stents later. There were no peri-procedure complications and the patient was discharged 2 days after the coronary intervention.

Follow-up coronary angiography was arranged 3 months later and revealed no significant in-stent restenosis over the distal RCA stent (Figure F). He received regular cardiovascular clinic follow-ups and continued treatment with aspirin, β-blocker and angiotensin-converting enzyme inhibitor.

D

Retained fractured guidewire fragments are rarely en-countered in percutaneous coronary interventions and occurs in approximately 0.1–0.2% of cases [6,7]. It is more common in procedures using special devices such as a rotablator or an X-sized thromboatherectomy cath-eter [8,9]. The possible complications include throm-bosis, emboli, sepsis, vessel dissection, and perforation [3]. Doorey et al reported that retained guidewire frag-ments in patent coronary arteries may cause arterial narrowing despite systemic anticoagulation [10].

Management of the retained guidewire fragment includes cardiac surgery, retrieval with a snare loop technique, two-wire technique, stent deployment within a guide catheter or the fragment can be left in situ with observation [6,11–13]. There are usually no defi-nite resolutions because of the varying conditions of the coronary circulation and the equipment used. Based on the risk-benefit comparison, the primary therapeutic option is interventional retrieval using specialized har-vesting devices. Despite their thrombogenicity, catheter remnants, stents or fractured guidewires need not be removed unless they protrude into the ascending aorta, which increases the risk for thrombotic embolization to cerebral or other peripheral vessels [3]. Guidewire segments retained for a long time within the coronary circulation may be benign, particularly when they are

entrapped with the total coronary occlusions or within a distal part of the vessel. It seems probable that the guidewire segment will become covered with an out-growth of vascular endothelium, rendering the wire segments immobile and non-thrombogenic [4,14]. To eliminate the guidewire fragment from the lumen and reduce the risk for coronary thrombosis, sealing the fractured fragment to the vessel wall with the use of stents was described after unsuccessful retrieval of the proximal fragment in the ascending aorta [15,16]. In the event of unsuccessful interventional retrieval and persistent signs of ischemia, patients should be referred to surgery [3]. Some fractured coronary guide-wire fragments with a proximal portion extending into the ascending aorta can be extracted [6]. Therefore, surgical interventions should be accompanied by transesophageal echocardiography to evaluate the distal extent of the guidewire or catheter remnants in the aorta if needed. If the results are positive or equivo-cal, the aortic root should be opened and explored [17]. To the best of our knowledge, advancing the frac-ture guidewire fragments in the distal coronary artery and sealing them to the vessel wall with the use of stent has not been reported. Without interfering with the stent deployment in the proximal and distal stenoses, it was left in situ and there was no acute thrombosis, and ischemic symptoms did not occur. This case demon-strates effective management of a retained guidewire, and no complications occurred peri-procedurally.

R

1. The Executive Yuan Department of Health. Leading Causes of Death, Taiwan Area. Taipei, Taiwan: The Execu-tive Yuan Department of Health, 2004. Available from: http://www.doh.gov.tw/statistic/english/2/1.xls [Date accessed: February 2, 2007]

2. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percuta-neous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 2006;113:e166–286. 3. Alexiou K, Kappert U, Knaut M, et al. Entrapped

coro-nary catheter remnants and stents: must they be surgi-cally removed? Tex Heart Inst J 2006;33:139–42.

4. Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equip-ment components and their manageequip-ment. Am J Cardiol 1987;60:1260–4.

C.Y. Chu, T.H. Lin, H.M. Su, et al

5. Brilakis ES, Best PJ, Elesber AA, et al. Incidence, retrieval methods, and outcomes of stent loss during per-cutaneous coronary intervention: a large single-center experience. Catheter Cardiovasc Interv 2005;66:333–40. 6. Watson LE. Snare loop technique for removal of broken

steerable PTCA wire. Cathet Cardiovasc Diagn 1987;13: 44–9.

7. Khonsari S, Livermore J, Mahrer P, et al. Fracture and dislodgment of floppy guidewire during percutaneous transluminal coronary angioplasty. Am J Cardiol 1986;58: 855–6.

8. Cafri C, Rosenstein G, Ilia R. Fracture of a coronary guidewire during graft thrombectomy with the X-sizer device. J Invasive Cardiol 2004;16:263–5.

9. Foster-Smith K, Garratt KN, Holmes DR Jr. Guidewire transection during rotational coronary atherectomy due to guide catheter dislodgement and wire kinking. Cathet Cardiovasc Diagn 1995;35:224–7.

10. Doorey AJ, Stillabower M. Fractured and retained guide-wire fragment during coronary angioplasty—unforeseen late sequelae. Cathet Cardiovasc Diagn 1990;20:238–40. 11. Patel T, Shah S, Pandya R, et al. Broken guidewire

frag-ment: a simplified retrieval technique. Catheter Cardiovasc Interv 2000;51:483–6.

12. Mintz GS, Bemis CE, Unwala AA, et al. An alternative method for transcatheter retrieval of intracoronary angio-plasty equipment fragments. Cathet Cardiovasc Diagn 1990;20:247–50.

13. Prasan A, Brieger D, Adams MR, et al. Stent deploy-ment within a guide catheter aids removal of a frac-tured buddy wire. Catheter Cardiovasc Interv 2002;56: 212–4.

14. Sethi GK, Ferguson TB Jr, Miller G, et al. Entrapment of broken guidewire in the left main coronary artery dur-ing percutaneous transluminal coronary angioplasty. Ann Thorac Surg 1989;47:455–7.

15. Lopez-Minguez JR, Davila E, Doblado M, et al. Rupture and intracoronary entrapment of an angioplasty guide-wire with the X-Sizer thromboatherectomy catheter during rescue angioplasty. Rev Esp Cardiol 2004;57: 180–3.

16. van Gaal WJ, Porto I, Banning AP. Guide wire fracture with retained filament in the LAD and aorta. Int J Cardiol 2006;112:e9–11.

17. Chang TM, Pellegrini D, Ostrovsky A, et al. Surgical management of entrapped percutaneous transluminal coronary angioplasty hardware. Tex Heart Inst J 2002;29: 329–32.

收文日期：96 年 2 月 12 日 接受刊載：98 年 3 月 3 日 通訊作者：林宗憲醫師 高雄醫學大學附設醫院心臟血管內科 高雄市三民區自由一路 100 號

冠狀動脈氣球擴張整型術中，遺留於冠狀動脈

導引線碎片的處理