Migration of a Broken Rotawire Across the Aorta During Retrieval Using the Twin Guidewire Method

Abstract

A 65-year-old man underwent percutaneous transluminal coronary rotational atherectomy for chronic total occlusion of the calcified left anterior descending coronary artery (LAD). During ablation with a 1.25 mm RotaLink burr, a Rotawire was transected at its radiolucent portion. Two conventional coronary guidewires were advanced deep into the LAD and were rotated to entangle the retained fragment of the Rotawire. After fixing this fragment with the guidewires, we drew it toward the guide catheter. During this procedure, the proximal radiolucent end of the fractured wire was not clearly visible on fluoroscopy, and the guidewires lost their grasp on the retained segment; the proximal end of this segment seemed to be migrating outside the guiding catheter and crossing the ascending aorta. Further attempts to retrieve the broken segment were unsuccessful. Multi-detector computed tomography showed that the retained fragment had penetrated the aortic wall, with its proximal end located in the right mediastinum. As illustrated in this case, the retrieval of a broken Rotawire using the twin wire method is problematic when the breakage has occurred at the wire’s radiolucent stiff portion.

Introduction

One of the complications of percutaneous coronary rotational transluminal atherectomy (PTCRA) is the breakage of the guidewire during ablation. This complication is not common, but it has been consistently reported.^1-5 Many methods for percutaneous retrieval of a fractured guidewire during percutaneous coronary intervention (PCI) have been suggested.^1,6-13 However, retrieval of the Rotawire is considered rather difficult if the breakage occurs at the radiolucent portion of the wire, because of the poor visibility of the proximal end of the broken segment under fluoroscopy.⁴ We describe a case in which fragment retrieval using the twin wire method¹¹ was unsuccessful; this resulted in penetration of the aortic wall by the proximal side of the fractured wire fragment.

Case report

Ten years ago, a 65-year-old man was admitted to our hospital with sudden chest pain and dyspnea. Patient history included cigarette smoking and diabetes mellitus. Electrocardiography showed ST elevation in the inferior leads. Emergent coronary angiography indicated total occlusion of the proximal portions of both the right coronary artery (RCA) and the left anterior descending artery (LAD). Further to the coronary angiography findings, primary PCI was performed to address the RCA occlusion. After successful percutaneous wiring to the occluding lesion, we deployed coronary artery stents and blood flow was restored. Seven days later, we performed PCI for the chronic total occlusion (CTO) of the LAD. After successful wire penetration as far as the lesion, we attempted to cross the occluded section with a 1.5 mm balloon catheter; however, we did not succeed in this attempt. We proceeded with PTCRA: a 0.009 inch Rotawire Floppy Gold (Boston Scientific) was used to cross the lesion and a 1.25 mm Rotablator burr (Boston Scientific) was advanced into the LAD (Figure 1). Ablation runs at 174,000–217,000 rpm were performed 15 times, with decrease in rpm maintained at <5000 and run times maintained at <20 seconds. The guidewire had no kinks or loops. After completion of the ablation, we planned to exchange the Rotawire with the conventional guidewire. The Rotawire retracted freely, but its tip remained in place at the left main coronary artery. The Rotawire was removed and examined: the tip of the wire was missing, with the break occurring at the radiolucent portion. The proximal portion of the transected segment remained in the left main coronary artery (Figure 2). A 4 mm Amplatz Goose Neck Microsnare Kit (ev3 Inc.) was used in an unsuccessful attempt to intercept the Rotawire at the left main coronary artery. Two Balance Middleweight BMW coronary guidewires (Abbott Vascular) were then advanced up to the distal part of the retained wire fragment; a torque device was connected to both wires and rotated to entangle the retained fragment (Figure 3). After fixing the Rotawire fragment, the guidewires were retracted slowly into the guide catheter. As the intertwined guidewires retracted, the Rotawire fragment initially moved toward the tip of the guide catheter, but then ceased to move any further. Cine mode fluoroscopy showed that the proximal part of the Rotawire fragment seemed to be crossing the ascending aorta, and it appeared to be trapped in the opposite aortic wall (Figure 4). We tried to retrieve the wire fragment with a pigtail catheter and a self-made snare, but these attempts were unsuccessful (Figure 5). The procedure was terminated at this point. The patient was treated with dual antiplatelet therapy, and no cardiac event occurred for the next ten years. At that time, he visited our outpatient department to undergo chest computed tomography (CT) for suspected lung cancer. A 64-row multi detector CT revealed that the Rotawire fragment was lodged between the right mediastinum and the proximal part of the LAD (Figure 6). The patient had remained asymptomatic throughout. 

Discussion

This report describes an unsuccessful attempt at retrieving a broken Rotawire, in which the proximal end of the broken segment penetrated the aortic wall during retraction using intertwined guide wires.¹¹ To the best of our knowledge, this is the first such case reported. This case illustrates several important issues in the retrieval of a broken fragment of Rotawire. First, the Rotawire has the thinnest shaft (0.009 inches) among the guidewires used for PCI,¹⁴ and the radiolucent shaft is difficult to recognize on fluoroscopic examination. Second, fracture of the Rotawire sometimes occurs in the proximal portion of the wire.³ Because the wire shaft is stiff enough to penetrate the plaque at this point, it is also stiff enough to penetrate a vessel wall during movement toward the proximal end of the coronary artery. Third, snaring is usually the first choice for capturing the broken segment of the guidewire, but as noted in the current case, intercepting the proximal end of the fragment within a diseased coronary artery is sometimes difficult, especially for an artery that has required ablation. Fourth, the aortocoronary angle of the left coronary artery varies from person to person¹⁵, and in some patients, the left coronary artery originates almost tangentially from the ascending aorta. In such cases, the proximal end of the retracted broken segment may easily penetrate the vessel wall. We believe the current case embodies the above conditions.

Among the many methods available for retrieving a broken segment of guidewire, the twin wire method has several advantages. This technique is relatively easy, cost effective, and instantly achievable without any special devices. In this case, however, friction between the intertwining wires and the original fragment served only to maintain the fixation of the broken segment when retraction was attempted. In addition, this technique is prone to releasing the broken segment when its proximal end becomes stuck at the vessel wall or catheter tip. The operator needs to be aware of these aspects of retrieving broken Rotawires using the twin wire method.

Retrieval of a broken Rotawire using the twin wire method is problematic when the breakage has occurred at the radiolucent portion of the wire. The case described herein illustrates this possibility and highlights the dangers posed by Rotawire breakage to surrounding structures.   

This manuscript underwent double-blind peer review by members of the Cath Lab Digest editorial board.

The authors may be contacted via Dr. Akihiko Takahashi at a-takahashi@wine.ocn.ne.jp.

References

1. Savas V, Schreiber T, O’Neill W. Percutaneous extraction of fractured guidewire from distal right coronary artery. Cathet Cardiovasc Diagn. 1991 Feb;22(2):124-126.
2. Safian RD, Niazi KA, Strzelecki M, Lichtenberg A, May MA, Juran N. Detailed angiographic analysis of high-speed mechanical rotational atherectomy in human coronary arteries. Circulation. 1993 Sep;88(3):961-968.
3. 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 Jul;35(3):224-227.
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. 2005 Dec;17(12):E55-E58.
5. FDAZilla.com. Data driven intelligence on the FDA. FDA Maude database search: Rotawire. Available online at https://www.fdazilla.com/fda/devices/maude/search?q=rotawire. Accessed January 17, 2013.
6. Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management.  Am J Cardiol. 1987 Dec 1;60(16):
7. 1260-1264.
8. Krone RJ. Successful percutaneous removal of retained broken coronary angioplasty guidewire. Cathet Cardiovasc Diagn. 1986;12(6):409-410.
9. Mikolich JR, Hanson MW. Transcatheter retrieval of intracoronary detached angioplasty guidewire segment. Cathet Cardiovasc Diagn. 1988;15(1):44-46.
10. Serota H, Deligonul U, Lew B, Kern MJ, Aguirre F, Vandormael M. Improved method for transcatheter retrieval of intracoronary detached angioplasty guidewire segments. Cathet Cardiovasc Diagn. 1989 Aug;17(4):248-251.
11. Mintz GS, Bemis CE, Unwala AA, Hadjimiltiades S, Kimbiris D. An alternative method for transcatheter retrieval of intracoronary angioplasty equipment fragments. Cathet Cardiovasc Diagn. 1990 Aug;20(4):247-250.
12. Gurley JC, Booth DC, Hixson C, Smith MD. Removal of retained intracoronary percutaneous transluminal coronary angioplasty equipment by a percutaneous twin guidewire method. Cathet Cardiovasc Diagn. 1990 Apr;19(4):251-256.
13. Pande AK, Doucet S. Percutaneous retrieval of transsected rotablator coronary guidewire using Amplatz “Goose-Neck snare”. Indian Heart J. 1998 Jul-Aug;50(4):439-442.
14. Hwang MH, Hsieh AA, Silverman P, Loeb HS. The fracture, dislodgement and retrieval of a probe III balloon-on-a-wire catheter. J Invasive Cardiol. 1994 Jun;6(5):154-156.
15. Mohiddin SA, Rothman MT. Ch 21: Rotational Atherectomy. In: Di Mario C, Dangas GD, Barlis P, eds. Interventional Cardiology: Principles and Practice. Oxford, UK: Wiley-Blackwell; 2011: 323-337.
16. Zamir M, Sinclair P. Roots and calibers of the human coronary arteries. Am J Anat. 1988 Nov;183(3):226-234.