Wire Fracture – Miscellaneous – Case 1
- 63-year-old female who presented with chest pain (CCS Class III), and was referred for staged PCI of the proximal LCx and OM1.
Past Medical History
- HTN, HLD, DM, CAD s/p Multiple PCI’s, Asthma
- LVEF 60%
- Prior Cardiac Catheterization: Proximal LAD 90-95% stenosis s/p successful PCI, proximal LCx 70-80% stenosis, high lateral 80-90% stenosis, OM1 80-90% stenosis.
- Home Medications: Aspirin, Ticagrelor, Atorvastatin, Atenolol, Fosinopril, Metformin, Pioglitazone
- Adjunct Pharmacotherapy: Ticagrelor, Bivalirudin
Left coronary artery angiography
- thrombotic 90-95% obstruction of stent placed in the proximal left anterior descending (LAD) coronary artery 36 days prior.
- bifurcation lesion of 70-80% proximal LCX and 80-90% in OM1.
- Underwent intervention of the LAD followed by intervention of the LCx with side branch (OM1) wiring.
- The LCx lesion was pre-dilated and the Fielder wire was removed from OM1. However, as the wire was being removed, the tip of the wire fractured and coiled within the ostium of OM1.
- A stent was placed in the proximal LCx, extending across the ostium of the OM1 branch.
- Troponin-I peaked at 0.08 ng/mL and CK-MB peaked at 1.5 ng/mL.
- Patient was discharged home next day without further sequelae.
- What is the likely explanation or reason why the complication occurred?
- Possible altered course of the wire (true lumen to false lumen and entry back into the true lumen) or entry of the wire through a calcified plaque, with wire being caught by the tissue or calcium during retrieval, fracturing it when it was being retracted.
- How could the complication have been prevented?
- Use a non-hydrophilic wire when performing bifurcation interventions to wire the side-branch.
- 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?
- Be very cautious when wiring a side branch with a significant ostial lesion.
- When a wire is fractured within a coronary vessel, an attempt should be made to percutaneously retrieve the remnant wire or exclude it with a stent, particularly if the remnant wire is located proximal in a large caliber vessel. If the remnant wire is located more distal, it is reasonable to defer intervention. In this case, we attempted to retrieve the remnant wire; however, there was difficulty in delivering devices/equipment across the ostium of the OM1 branch due to its angulation, and further attempts to retrieve the remnant wire or exclude it was a stent were deferred.