Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Entrapped Devices after PCI Ihab Alomari a,⁎, Richard Snider b, Sonia Ponce a, Bina Ahmed b a b
Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico Division of Cardiology, University of New Mexico School of Medicine and Veterans Affairs Medical Center, Albuquerque, NM
a r t i c l e
i n f o
Article history: Received 15 August 2013 Received in revised form 2 October 2013 Accepted 14 October 2013 Available online xxxx Keywords: Entrapped devices Guidewire fracture Coronary device entrapment
a b s t r a c t In contemporary practice, entrapped devices are rarely encountered during percutaneous coronary intervention (PCI) but can be associated with serious morbidity and mortality. We present a case of a 62 y/ o male who presented with an acute coronary syndrome. Revascularization was performed and complicated by guide wire entrapment and fracture. Cardiologists should be aware of this complication and the treatment options available. © 2013 Elsevier Inc. All rights reserved.
1. Case report A 62 y/o man with a history of hypertension and ongoing tobacco use presented to the emergency room with 2 weeks of intermittent and progressive weakness, near syncope and anginal quality chest discomfort. Initial ECG demonstrated sinus rhythm with complete heart block and a wide QRS ventricular rate of 41 bpm. There was evidence of ST segment elevation in the inferior leads concerning for an inferior ST elevation myocardial infarction (STEMI). The patient was taken emergently to the catheterization lab after receiving oral aspirin 325 mg, clopidogrel 600 mg and 5000 unit IV heparin bolus. A temporary pacing wire was placed in the right ventricle via 6 F femoral vein approach. Coronary angiography revealed a 100% thrombotic occlusion of the proximal RCA with non-obstructive disease in the left coronary system and no evidence of left to right collateral flow (Fig. 1). Given ongoing chest pain with complete heart block, the decision was made to pursue primary percutaneous coronary intervention (PCI). A 6 F JR4 (Medtronic) guide was used via the right femoral artery approach for intervention. The lesion was crossed without difficulty using an Abbott vascular ASAHI prowater 0.014”/180 cm wire. After several balloon inflations in the proximal to mid RCA using an Emerge Monorail 2.5 mm × 15 mm (Boston Scientific) balloon, there was evidence of diffuse disease extending from proximal to the distal segment of the RCA. TIMI III flow was achieved with placement of three overlapping drug eluting stents (Xience Xpedition, Abott Vascular Santa Clara, CA). Two stents were placed in the mid to distal RCA (2.5 × 28 mm, 2.5 × 28 mm) in an overlapping ⁎ Corresponding author. University of New Mexico Hospitals Department of Cardiology MSC 10-5550 1 University of New Mexico Albuquerque, NM 87131 United States. Tel.: +15055731457; fax: +15052724356. E-mail address: [email protected] (I. Alomari).
fashion. Stents were deployed at 14 atm. Intra vascular ultrasound (IVUS) (Eagle eye platinum coronary imaging catheter, Volcano Therapeutics Coyol Alajuela, Costa Rica) was then performed to evaluate a hazy area in the proximal RCA. There was some difficulty passing the IVUS catheter into the mid RCA over the proximal stent edge in the mid RCA but we were able to use IVUS to confirm the presence of severe plaque proximal to the stented segment in the mid RCA. The decision was made to place an additional stent (third) in the proximal RCA. (Fig. 2). Attempts at passing a 3.5 × 15 mm DES was difficult with similar resistance which was encountered with the IVUS catheter at the proximal edge of the stent in the mid RCA. Attempts at placing the stent did result in movement of the distal portion of the coronary wire although wire position was never completely lost in the RCA. Eventually, the stent was positioned in the proximal RCA overlapping with the stent in mid RCA. The stent was deployed at 14 atm and the stent balloon was re-inflated at the stent overlap site at 14 atm. The stent balloon was removed without difficulty but we were unable to remove the guidewire. The guide wire appeared entrapped between stents in the proximal and mid RCA. Attempts at removing the guidewire resulted in sheering of an approximate 8-10 cm portion of the wire including the radio-opaque portion of the wire (Figs. 3 and 4). The proximal end of the sheered wire extended into the right coronary cusp of the aorta (3-4 cm). The patient remained hemodynamically stable with TIMI 3 flow. The decision was made to abort the case and discuss further management options. The patient was transferred to the Medical Intensive care unit on triple anti-platelet therapy (ASA, plavix and integrillin). He did require transient pressor support for presumed right ventricular infarct and on day three he was weaned off pressor support with recovery of sinus node function. The patient did undergo follow-up angiography prior to discharge which showed a patent RCA with TIMI 3 flow and coronary wire unchanged in position from prior cath. After
1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.10.004
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
2
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
JR 4 Guide catheter JR 4 guider RCA occlusion
Fractured wire Fractured wire External cutaneous pacer wire
Temporary pacer wire
Fig. 1. Antero-posterior cranial view shows proximal RCA occlusion. RCA: Right coronary artery, JR: Judkins right catheter.
discussing risks and benefits of removal of the wire, either surgically or percutaneously versus conservative management, a decision was made to manage conservatively. The patient was discharged home on day ten on dual antiplatelet therapy.
2. Discussion In contemporary practice, entrapped devices including catheters, balloons and guidewires, are rarely encountered during PCI but can be associated with serious morbidity and mortality [1,2]. The possible complications of retained devices include thrombosis, embolization, sepsis, vessel dissection, and perforation. There are limited data to guide management of retained devices. This review summarizes
Fig. 3. AP view showing the fractured wire extending from the mid RCA to the right coronary cusp.
existing literature on management and outcomes related to entrapped devices during PCI. Over the last two decades, several case reports and small case series have described management and outcomes in patients with entrapped devices (Table 1). Consideration is given to surgical or percutaneous removal of the device versus leaving the device in situ. Factors such as type of device retained, risk of retrieval, risk of retention, clinical stability and anatomy all come into play when considering the best short and long term outcome. In a small series, Alexiou et al report their experience with surgical removal of retained devices [1]. Nine patients underwent successful surgical intervention emergently for retained guidewire fragments (n = 3), rotoblator burr (n = 2) or entrapped stent
JR 4 Guide catheter
Fractured wire Temporary pacer wire Proximal stent deployment
External cutaneous pacer wire
Zoll pad compression sensor Zoll pad compression sensor
Fig. 2. LAO view shows the proximal stent deployment in the RCA.
Fig. 4. LAO view showes the fractured wire during contrast filling.
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
3
Table 1 Review of Case Reports and Case Series. Study
Wire/device Name
Site of trapping
Mechanism of trapping
Length
Treatment
Success
Complications
Hatzler
Gold floppy (2) Flexible/Steerable High Torque LPS guidewire⁎ (3) Microbore-I Gold Band Guide wires Rotoblator Stents
Torque & withdrawing N/A N/A N/A Extreme torquing Lateral stress N/A
N20 cm 5 cm 2 cm 1 cm 3 cm
Alexio
Pigtail catheter Left Amplatz Balloon withdrawal Conservative Conservative Balloon withdrawl Conservative Surgical Removal
Yes Yes No N/A N/A Yes N/AYes
No Embolized⁎⁎ No No No No No No
Modi Al-Amri Hong
Guidewire Guidewire BMW Guidewire
Mid RCA(1) Distal LCX(1) RCA LCX LCX(2), LAD(1) LCX Distal LCX LAD(2), RCA(1) RCA(2) LAD(3) Ramus(1) LAD extending in to the aorta LAD extending in to the aorta LAD
N/A Entrapped in stent struts N/A
N/A N/A N/A
Yes Yes No
Gaal
Guidant Guidewire
LAD
Entrapped in the lesion
N/A
Kaplan
Guidwire
RCA
Excessive tensile force or entrapment by stent struts
1.5-2 cm
Surgical Removal Surgery Snare Conservative Snare Conservative N/A
None No (6 months) No (12 months) No (8 months) No (2 years)
N/A
No N/A
⁎ Advanced Cardiovascular systems LAD: Left anterior descending artery; RCA: Right coronary artery; LCX: Left circumflex artery. ⁎⁎ The extracted wire embolized to a pelvic artery during snaring. It was subsequently removed using a Caves-schultz bioptome.
(n = 4). All patients survived without any short term complications. Authors recommended leaving entrapped devices in situ if these are contained within small, chronically occluded coronary vessels or within a distal segment and proceeding with surgical revascularization as clinically necessary. An alternative to surgical removal is percutaneous retrieval. Use of snares, balloons, forceps and bioptomes all have been reported (Table 2). Retrieval of an entrapped device contained entirely within the coronary tree often times is challenging and depends on the site and size of vessel the retained device has embolized to. For retained guidewire fragments in the distal coronary tree, case reports have described successful removal by twisting two guidewires around the retained guidewire portion and then removing it into the proximal portion of the vessel and into the guide catheter [3]. Another technique involves inflating a balloon distal to the entrapped wire and using it to push the fragment into the proximal vessel. [2]. Gavlick et al described a case report using a microvena snare catheter (eV3, Plymouth Minnesota) to successfully extract a fractured rota-floppy wire fragment from a distal coronary artery [4]. Hatzler et al evaluated 5,400 consecutive patients undergoing percutaneous procedures. 12 patients had complications associated with retention of devices mainly fractured guidewires [2]. Guidewire fragments were retained within the coronary circulation in 9 of these patients. Three of the four extraction procedures attempted were successful. On follow up, 6 patients with chronically retained wire fragments had no sequelea associated with retained equipment up to 5 yr follow-up (6-60 months). There were two deaths which were
Table 2 Retrieval Devices. Device Snares (snare diameter and length) One snare (5-35 mm; 65-120 mm) EN snare (2-45 mm; 120-175 mm) Amplatz Goose neck snare (5-35 mm; 65-120 mm) Amplatz Goose neck micro-snare (2-7 mm; 175-200 mm) Atrieve vascular snare (2-45 mm, 120-175 mm) Forceps (length) Vascular retrieval forceps (120 cm) Biopsy Forceps (length) Jawz (105 cm) ProCure (105 cm) BiPal (50 cm)
Manufacturer Merit Medical Merit Medical Covidien Covidien Angiotech Cook Medical Argon Medical St Jude Medical Cordis
unrelated to retained device and one patient underwent surgical revascularization three months later also unrelated to retained device. For guidewires extending into the aorta, use of snares and bioptomes can be attempted but come with a risk of embolization into cerebral or distal aortic circulation [2]. In the Hatzler report, two patients had a guidewire extending from the coronary tree into the ascending aorta. Attempts at snaring these were successful in both patients however there was embolization of the retained guidewire into the lower vasculature in one patient during retrieval. The wire was then successfully extracted from the lower extremity. Conservative management does carry the risk of subsequent ischemia, related thrombus formation or embolization. Modi et al reported a case of unexpected guidewire retention which was managed medically with dual antiplatelet therapy (aspirin and clopidogrel). Two weeks after the event, the patient had recurrence of chest pain that did not respond to anti-anginal therapy. Imaging revealed a coil wire extending into the ascending aorta for which he underwent surgical removal. At 12 weeks follow up the patient was doing well [5]. Similarly, Al-Amiri et al reported a case of retained guidewire used to protect a diagonal branch while fixing the LAD. Post procedure, the patient had acute stent thrombosis and was subsequently referred for surgical removal of the guidewire. The patient underwent a left internal mammary to LAD graft. The guidewire was difficult to remove; therefore the wire was cut close to the LAD stent. At 6 month follow up, the patient had evidence of patent left main and LIMA to LAD graft [6]. On the other hand, Hong et al [7] reported a retained guidewire fragment in the LAD extending to the aorta. Percutaneous retrieval was unsuccessful and patient was managed conservatively without complications at 1 year. Similarly, Gaal et al treated a patient with retained fractured wire in the LAD and aorta conservatively without significant sequelea at 8 months [8]. Kaplan et al reported a fractured guidewire in the RCA that was treated conservatively with no complications at 2 year follow up [9]. These cases highlight the safety of conservative management in the appropriate patient. In our case, the mechanism of wire entrapment and fracture may have involved sliding of the distal end of the guidewire behind overlapping stent struts in the mid to distal RCA while attempting to place the proximal RCA stent. The wire may have become more fully entrapped after aggressive post dilation balloon inflation at the stent overlap site between the proximal and mid stents. Our decision to manage the patient conservatively was based upon consideration of the clinical risk of surgical removal and risk of embolization with percutaneous removal. After review of the literature and discussion
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
4
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
with the family, we decided to treat the patient conservatively with lifelong dual anti platelet therapy. The patient was seen in follow-up at 4 months and is without any complications. In conclusion, retained devices are rare in contemporary practice but can lead to significant morbidity and mortality. Management is predicated in large part on the type of device entrapped, location of the retained device and patients’ clinical condition. For patients who are acutely ischemic or unstable, either percutaneous or surgical removal should be considered using various techniques described above. Among stable patients, treatment decisions should be individualized weighing the risk and benefits of removal versus conservative management. References [1] Alexiou K, Kappert U, Knaut M. Entrapped coronary catheter remnants and stents: must they be surgically removed? Tex Heart Inst J 2006;33:139–42.
[2] Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260–4. [3] Demircan S, Yazici M, Durna K, Yasar E. Intracoronary guidewire emboli: a unique complication and retrieval of the wire. Cardiovasc Revasc Med Oct-Dec 2008;9(4): 278–80. http://dx.doi.org/10.1016/j.carrev.2007.11.003. [4] Gavlick K, Blankenship JC. Snare retrieval of the distal tip of a fractured rotational atherectomy guidewire: roping the steer by its horns. J Invasive Cardiol Dec 2005;17(12):E55-8 (Review). [5] Modi A, Zorinas A, Vohra H. Delayed surgical Retrieval of Retained Guidewire Following Percutaneous Coronary Intervention. J Card Surg 2011;26:37–68. [6] Al-Amri H. Al-Moghairi, Calafiore A: Left main approach for retrieval of retained guidewire fragment. J Card Surg 2012;27:299–330. [7] Hong YM, Lee SRA. Case of Guide Wire Fracture With Remnant Filaments in the Left Anterior Descending Coronary Artery and Aorta. Korean Circ J 2010 September;40(9):475–7. [8] 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. [9] Kaplan Sahin, Tuba Kaplan Safiye, Kutlu Merih. An unusual case of guide wire fractured during primary percutaneous coronary intervention, and two year follow − up. Cathet Cardiovasc Diagn 1988;15(2):99–102.
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Entrapped Devices after PCI Ihab Alomari a,⁎, Richard Snider b, Sonia Ponce a, Bina Ahmed b a b
Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico Division of Cardiology, University of New Mexico School of Medicine and Veterans Affairs Medical Center, Albuquerque, NM
a r t i c l e
i n f o
Article history: Received 15 August 2013 Received in revised form 2 October 2013 Accepted 14 October 2013 Available online xxxx Keywords: Entrapped devices Guidewire fracture Coronary device entrapment
a b s t r a c t In contemporary practice, entrapped devices are rarely encountered during percutaneous coronary intervention (PCI) but can be associated with serious morbidity and mortality. We present a case of a 62 y/ o male who presented with an acute coronary syndrome. Revascularization was performed and complicated by guide wire entrapment and fracture. Cardiologists should be aware of this complication and the treatment options available. © 2013 Elsevier Inc. All rights reserved.
1. Case report A 62 y/o man with a history of hypertension and ongoing tobacco use presented to the emergency room with 2 weeks of intermittent and progressive weakness, near syncope and anginal quality chest discomfort. Initial ECG demonstrated sinus rhythm with complete heart block and a wide QRS ventricular rate of 41 bpm. There was evidence of ST segment elevation in the inferior leads concerning for an inferior ST elevation myocardial infarction (STEMI). The patient was taken emergently to the catheterization lab after receiving oral aspirin 325 mg, clopidogrel 600 mg and 5000 unit IV heparin bolus. A temporary pacing wire was placed in the right ventricle via 6 F femoral vein approach. Coronary angiography revealed a 100% thrombotic occlusion of the proximal RCA with non-obstructive disease in the left coronary system and no evidence of left to right collateral flow (Fig. 1). Given ongoing chest pain with complete heart block, the decision was made to pursue primary percutaneous coronary intervention (PCI). A 6 F JR4 (Medtronic) guide was used via the right femoral artery approach for intervention. The lesion was crossed without difficulty using an Abbott vascular ASAHI prowater 0.014”/180 cm wire. After several balloon inflations in the proximal to mid RCA using an Emerge Monorail 2.5 mm × 15 mm (Boston Scientific) balloon, there was evidence of diffuse disease extending from proximal to the distal segment of the RCA. TIMI III flow was achieved with placement of three overlapping drug eluting stents (Xience Xpedition, Abott Vascular Santa Clara, CA). Two stents were placed in the mid to distal RCA (2.5 × 28 mm, 2.5 × 28 mm) in an overlapping ⁎ Corresponding author. University of New Mexico Hospitals Department of Cardiology MSC 10-5550 1 University of New Mexico Albuquerque, NM 87131 United States. Tel.: +15055731457; fax: +15052724356. E-mail address: [email protected] (I. Alomari).
fashion. Stents were deployed at 14 atm. Intra vascular ultrasound (IVUS) (Eagle eye platinum coronary imaging catheter, Volcano Therapeutics Coyol Alajuela, Costa Rica) was then performed to evaluate a hazy area in the proximal RCA. There was some difficulty passing the IVUS catheter into the mid RCA over the proximal stent edge in the mid RCA but we were able to use IVUS to confirm the presence of severe plaque proximal to the stented segment in the mid RCA. The decision was made to place an additional stent (third) in the proximal RCA. (Fig. 2). Attempts at passing a 3.5 × 15 mm DES was difficult with similar resistance which was encountered with the IVUS catheter at the proximal edge of the stent in the mid RCA. Attempts at placing the stent did result in movement of the distal portion of the coronary wire although wire position was never completely lost in the RCA. Eventually, the stent was positioned in the proximal RCA overlapping with the stent in mid RCA. The stent was deployed at 14 atm and the stent balloon was re-inflated at the stent overlap site at 14 atm. The stent balloon was removed without difficulty but we were unable to remove the guidewire. The guide wire appeared entrapped between stents in the proximal and mid RCA. Attempts at removing the guidewire resulted in sheering of an approximate 8-10 cm portion of the wire including the radio-opaque portion of the wire (Figs. 3 and 4). The proximal end of the sheered wire extended into the right coronary cusp of the aorta (3-4 cm). The patient remained hemodynamically stable with TIMI 3 flow. The decision was made to abort the case and discuss further management options. The patient was transferred to the Medical Intensive care unit on triple anti-platelet therapy (ASA, plavix and integrillin). He did require transient pressor support for presumed right ventricular infarct and on day three he was weaned off pressor support with recovery of sinus node function. The patient did undergo follow-up angiography prior to discharge which showed a patent RCA with TIMI 3 flow and coronary wire unchanged in position from prior cath. After
1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.10.004
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
2
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
JR 4 Guide catheter JR 4 guider RCA occlusion
Fractured wire Fractured wire External cutaneous pacer wire
Temporary pacer wire
Fig. 1. Antero-posterior cranial view shows proximal RCA occlusion. RCA: Right coronary artery, JR: Judkins right catheter.
discussing risks and benefits of removal of the wire, either surgically or percutaneously versus conservative management, a decision was made to manage conservatively. The patient was discharged home on day ten on dual antiplatelet therapy.
2. Discussion In contemporary practice, entrapped devices including catheters, balloons and guidewires, are rarely encountered during PCI but can be associated with serious morbidity and mortality [1,2]. The possible complications of retained devices include thrombosis, embolization, sepsis, vessel dissection, and perforation. There are limited data to guide management of retained devices. This review summarizes
Fig. 3. AP view showing the fractured wire extending from the mid RCA to the right coronary cusp.
existing literature on management and outcomes related to entrapped devices during PCI. Over the last two decades, several case reports and small case series have described management and outcomes in patients with entrapped devices (Table 1). Consideration is given to surgical or percutaneous removal of the device versus leaving the device in situ. Factors such as type of device retained, risk of retrieval, risk of retention, clinical stability and anatomy all come into play when considering the best short and long term outcome. In a small series, Alexiou et al report their experience with surgical removal of retained devices [1]. Nine patients underwent successful surgical intervention emergently for retained guidewire fragments (n = 3), rotoblator burr (n = 2) or entrapped stent
JR 4 Guide catheter
Fractured wire Temporary pacer wire Proximal stent deployment
External cutaneous pacer wire
Zoll pad compression sensor Zoll pad compression sensor
Fig. 2. LAO view shows the proximal stent deployment in the RCA.
Fig. 4. LAO view showes the fractured wire during contrast filling.
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
3
Table 1 Review of Case Reports and Case Series. Study
Wire/device Name
Site of trapping
Mechanism of trapping
Length
Treatment
Success
Complications
Hatzler
Gold floppy (2) Flexible/Steerable High Torque LPS guidewire⁎ (3) Microbore-I Gold Band Guide wires Rotoblator Stents
Torque & withdrawing N/A N/A N/A Extreme torquing Lateral stress N/A
N20 cm 5 cm 2 cm 1 cm 3 cm
Alexio
Pigtail catheter Left Amplatz Balloon withdrawal Conservative Conservative Balloon withdrawl Conservative Surgical Removal
Yes Yes No N/A N/A Yes N/AYes
No Embolized⁎⁎ No No No No No No
Modi Al-Amri Hong
Guidewire Guidewire BMW Guidewire
Mid RCA(1) Distal LCX(1) RCA LCX LCX(2), LAD(1) LCX Distal LCX LAD(2), RCA(1) RCA(2) LAD(3) Ramus(1) LAD extending in to the aorta LAD extending in to the aorta LAD
N/A Entrapped in stent struts N/A
N/A N/A N/A
Yes Yes No
Gaal
Guidant Guidewire
LAD
Entrapped in the lesion
N/A
Kaplan
Guidwire
RCA
Excessive tensile force or entrapment by stent struts
1.5-2 cm
Surgical Removal Surgery Snare Conservative Snare Conservative N/A
None No (6 months) No (12 months) No (8 months) No (2 years)
N/A
No N/A
⁎ Advanced Cardiovascular systems LAD: Left anterior descending artery; RCA: Right coronary artery; LCX: Left circumflex artery. ⁎⁎ The extracted wire embolized to a pelvic artery during snaring. It was subsequently removed using a Caves-schultz bioptome.
(n = 4). All patients survived without any short term complications. Authors recommended leaving entrapped devices in situ if these are contained within small, chronically occluded coronary vessels or within a distal segment and proceeding with surgical revascularization as clinically necessary. An alternative to surgical removal is percutaneous retrieval. Use of snares, balloons, forceps and bioptomes all have been reported (Table 2). Retrieval of an entrapped device contained entirely within the coronary tree often times is challenging and depends on the site and size of vessel the retained device has embolized to. For retained guidewire fragments in the distal coronary tree, case reports have described successful removal by twisting two guidewires around the retained guidewire portion and then removing it into the proximal portion of the vessel and into the guide catheter [3]. Another technique involves inflating a balloon distal to the entrapped wire and using it to push the fragment into the proximal vessel. [2]. Gavlick et al described a case report using a microvena snare catheter (eV3, Plymouth Minnesota) to successfully extract a fractured rota-floppy wire fragment from a distal coronary artery [4]. Hatzler et al evaluated 5,400 consecutive patients undergoing percutaneous procedures. 12 patients had complications associated with retention of devices mainly fractured guidewires [2]. Guidewire fragments were retained within the coronary circulation in 9 of these patients. Three of the four extraction procedures attempted were successful. On follow up, 6 patients with chronically retained wire fragments had no sequelea associated with retained equipment up to 5 yr follow-up (6-60 months). There were two deaths which were
Table 2 Retrieval Devices. Device Snares (snare diameter and length) One snare (5-35 mm; 65-120 mm) EN snare (2-45 mm; 120-175 mm) Amplatz Goose neck snare (5-35 mm; 65-120 mm) Amplatz Goose neck micro-snare (2-7 mm; 175-200 mm) Atrieve vascular snare (2-45 mm, 120-175 mm) Forceps (length) Vascular retrieval forceps (120 cm) Biopsy Forceps (length) Jawz (105 cm) ProCure (105 cm) BiPal (50 cm)
Manufacturer Merit Medical Merit Medical Covidien Covidien Angiotech Cook Medical Argon Medical St Jude Medical Cordis
unrelated to retained device and one patient underwent surgical revascularization three months later also unrelated to retained device. For guidewires extending into the aorta, use of snares and bioptomes can be attempted but come with a risk of embolization into cerebral or distal aortic circulation [2]. In the Hatzler report, two patients had a guidewire extending from the coronary tree into the ascending aorta. Attempts at snaring these were successful in both patients however there was embolization of the retained guidewire into the lower vasculature in one patient during retrieval. The wire was then successfully extracted from the lower extremity. Conservative management does carry the risk of subsequent ischemia, related thrombus formation or embolization. Modi et al reported a case of unexpected guidewire retention which was managed medically with dual antiplatelet therapy (aspirin and clopidogrel). Two weeks after the event, the patient had recurrence of chest pain that did not respond to anti-anginal therapy. Imaging revealed a coil wire extending into the ascending aorta for which he underwent surgical removal. At 12 weeks follow up the patient was doing well [5]. Similarly, Al-Amiri et al reported a case of retained guidewire used to protect a diagonal branch while fixing the LAD. Post procedure, the patient had acute stent thrombosis and was subsequently referred for surgical removal of the guidewire. The patient underwent a left internal mammary to LAD graft. The guidewire was difficult to remove; therefore the wire was cut close to the LAD stent. At 6 month follow up, the patient had evidence of patent left main and LIMA to LAD graft [6]. On the other hand, Hong et al [7] reported a retained guidewire fragment in the LAD extending to the aorta. Percutaneous retrieval was unsuccessful and patient was managed conservatively without complications at 1 year. Similarly, Gaal et al treated a patient with retained fractured wire in the LAD and aorta conservatively without significant sequelea at 8 months [8]. Kaplan et al reported a fractured guidewire in the RCA that was treated conservatively with no complications at 2 year follow up [9]. These cases highlight the safety of conservative management in the appropriate patient. In our case, the mechanism of wire entrapment and fracture may have involved sliding of the distal end of the guidewire behind overlapping stent struts in the mid to distal RCA while attempting to place the proximal RCA stent. The wire may have become more fully entrapped after aggressive post dilation balloon inflation at the stent overlap site between the proximal and mid stents. Our decision to manage the patient conservatively was based upon consideration of the clinical risk of surgical removal and risk of embolization with percutaneous removal. After review of the literature and discussion
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
4
I. Alomari et al. / Cardiovascular Revascularization Medicine xxx (2013) xxx–xxx
with the family, we decided to treat the patient conservatively with lifelong dual anti platelet therapy. The patient was seen in follow-up at 4 months and is without any complications. In conclusion, retained devices are rare in contemporary practice but can lead to significant morbidity and mortality. Management is predicated in large part on the type of device entrapped, location of the retained device and patients’ clinical condition. For patients who are acutely ischemic or unstable, either percutaneous or surgical removal should be considered using various techniques described above. Among stable patients, treatment decisions should be individualized weighing the risk and benefits of removal versus conservative management. References [1] Alexiou K, Kappert U, Knaut M. Entrapped coronary catheter remnants and stents: must they be surgically removed? Tex Heart Inst J 2006;33:139–42.
[2] Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260–4. [3] Demircan S, Yazici M, Durna K, Yasar E. Intracoronary guidewire emboli: a unique complication and retrieval of the wire. Cardiovasc Revasc Med Oct-Dec 2008;9(4): 278–80. http://dx.doi.org/10.1016/j.carrev.2007.11.003. [4] Gavlick K, Blankenship JC. Snare retrieval of the distal tip of a fractured rotational atherectomy guidewire: roping the steer by its horns. J Invasive Cardiol Dec 2005;17(12):E55-8 (Review). [5] Modi A, Zorinas A, Vohra H. Delayed surgical Retrieval of Retained Guidewire Following Percutaneous Coronary Intervention. J Card Surg 2011;26:37–68. [6] Al-Amri H. Al-Moghairi, Calafiore A: Left main approach for retrieval of retained guidewire fragment. J Card Surg 2012;27:299–330. [7] Hong YM, Lee SRA. Case of Guide Wire Fracture With Remnant Filaments in the Left Anterior Descending Coronary Artery and Aorta. Korean Circ J 2010 September;40(9):475–7. [8] 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. [9] Kaplan Sahin, Tuba Kaplan Safiye, Kutlu Merih. An unusual case of guide wire fractured during primary percutaneous coronary intervention, and two year follow − up. Cathet Cardiovasc Diagn 1988;15(2):99–102.
Please cite this article as: Alomari I, et al, Entrapped Devices after PCI, Cardiovasc Revasc Med (2013), http://dx.doi.org/10.1016/ j.carrev.2013.10.004
