Wire Fracture – Atherectomy – Case 1
- 62-year-old male who presented to the hospital with chest pain (CCS Class III) and was referred for protected LM-LCx PCI.
Past Medical History
- HTN, HLD, DM, CAD s/p 4-Vessel CABG, CKD
- LVEF 55%
- Stress MPI: Severe anterior wall & lateral wall ischemia.
- Prior Cardiac Catheterization: Distal LM 80-90% ISR, proximal LAD CTO, mid LAD 80-90% stenosis and retrograde fills via LIMA, proximal LCx 70-80% ISR, OM1 subtotal and fills via SVG, LPL subtotal, PRDA 60-70% stenosis; LIMA to Mid LAD patent, SVG to Distal RCA CTO, SVG to LCx OM1 proximal 90-95% ISR s/p successful PCI.
- Home Medications: Aspirin, Ticagrelor, Atorvastatin, Fenofibrate, Metoprolol Tartrate, Ranolazine, Benazepril, Hydrochlorothiazide, Glipizide
- Adjunct Pharmacotherapy: Ticagrelor, Bivalirudin
- total occlusion of the left anterior descending (LAD) artery
- 80-90% in-stent restenosis of the left main (LM)
- 80-90% in-stent restenosis in the proximal left circumflex (LCx) coronary artery
- Underwent intervention of LM-LCx in-stent restenosis.
- While performing rotational atherectomy of the LM extending into the LCx, the Rota Extra Support wire fractured in the lumen of the LCx.
- A stent was placed in the proximal LCx, anchoring the remnant wire.
- Procedure was continued and the patient underwent successful intervention of the LM.
- Troponin-I peaked at 0.13 ng/ML and CK-MB peaked at 0.6 ng/mL.
- Patient was discharged home the next day without further sequelae.
- What is the likely explanation or reason why the complication occurred?
- The Rota Extra Support wire was transected as the rota burr was advanced across the tortuous segment of the vessel.
- How could the complication have been prevented?
- Rotational atherectomy should be considered on a case by case bases, especially when the lesion is long, severely calcified and/or with severe angulation/tortuosity. Rotational atherectomy, orbital atherectomy and laser atherectomy were not suitable in this case. This case was best suited for atherectomy using a cutting/scoring balloon. Alternatively, off label use (in the USA) of intravascular Lithotripsy (IVL) for plaque modification and treatment of calcified CAD could have been considered.
- Is there an alternate strategy that could have been used to manage the complication?
- Snare Technique: Retrieval of a lost/remnant guidewire is feasible with a GooseNeck snare or a Triple-Loop snare. It is usually easier to retrieve a fragmented/remnant guidewire if it is located proximally in a large coronary artery. Success also depends on an operators familiarity with use of the snare and ability to align the loop of the snare to the guidewire. When using a snare, need to make sure its length is longer than the length of the guide catheter being used.
- Multi-Wire Technique: Insert one or two coronary wires next to the remnant wire and twist the wires together so all wires become entangled, and can be removed together.
- Balloon-Trapping Guide-Extension Catheter Technique: A balloon is used to jail the remnant wire against the lumen of a guide catheter or guide-extension catheter.
- If a remnant wire is still within a guide catheter, retrieval using this method involves inserting another wire distal to the remnant wire, thread a balloon over it and inflate the balloon inside the guide catheter to entrap the wire between the inflated balloon and wall of the catheter, followed by removal of the entire system simultaneously.
- If the remnant wire is outside the guide catheter, insert a second wire distal to the remnant wire and use a guide extension catheter to get the proximal part of the fractured wire into the lumen of the guide extension catheter. If successful, deliver a balloon and inflate the balloon to trap the wire between the balloon and lumen of the extension catheter, followed by removal of the entire system simultaneously.
- Using a stent to plaster the wire should only be considered as a last resort, especially if the wire is located more proximally in a large caliber vessel.
- What are the important learning points?
- An interventional cardiologist who uses rotablation, must be familiar with complications associated with its use and their management.
- NEVER use faulty or damaged equipment. If the equipment being used during a procedure is faulty or damaged, immediately remove and discarded the piece of equipment, or secure it for it to be sent back to the manufacturer.