Triple Wire Technique for Removal of Fractured Angioplasty
Guidewire

In the performance of increasingly complex percutaneous coronary interventions (PCIs), there remains an ever-present risk of device fracture or dislodgement. Such occurrences are fortunately infrequent,¹ however, they may pose an unfamiliar and difficult problem for the treating interventional cardiologist. While surgical^2,3 and conservative⁴ therapies have been employed, various percutaneous retrieval methods of variable complexity have been described.^5–12

We report a simple and effective method of extraction of a fractured angioplasty guidewire using 3 standard 0.014 inch angioplasty guidewires. This technique was effective in removal of the fractured guidewire and is suitable for retrieval in small- and medium-sized vessels.

Case Report. An 80-year old male with a history of dyslipidemia and hypertension presented with chest discomfort on a background of known coronary artery disease. The patient had undergone coronary artery bypass grafting in 1998 with a left internal mammary artery graft to the left anterior descending artery, and saphenous vein bypass grafts to the distal right coronary artery and the obtuse marginal artery. The patient had also undergone previous pacemaker insertion for documented bradycardia. On presentation, the patient was hemodynamically stable with no clinical evidence of left ventricular failure. The electrocardiogram demonstrated a paced rhythm, with normal serial troponin measurements. Due to ongoing rest discomfort, the patient proceeded to coronary angiography. Diagnostic catheterization performed from the right femoral artery demonstrated an occluded left anterior descending artery after the origin of a large bifurcating diagonal branch. There was a long segment of disease in the large diagonal branch involving the ostium of the side branch (Figure 1A). The left circumflex artery was small and diffusely diseased. The right coronary artery was diffusely diseased, with no hemodynamically significant stenoses. The left internal mammary graft was widely patent, with occlusions of the saphenous vein grafts to the obtuse marginal and right coronary artery branches.

The patient proceeded to percutaneous coronary intervention of the diagonal branch bifurcation stenosis. A 7 Fr Voda left guide catheter (Boston Scientific Corp., Natick, Massachusetts) was positioned at the origin of the left main coronary artery and a Balance Middleweight (BMW) 0.014 inch guidewire (Guidant Corp., Indianapolis, Indiana) was introduced into the distal diagonal artery. Intra-arterial heparin was administered to achieve an activated clotting time of more than 250 seconds and intravenous eptifibatide was commenced. The main vessel was predilated with a 2.5 x 15 mm Sprinter balloon (Medtronic, Inc., Minneapolis, Minnesota) and then stented with a 3.0 x 24 mm Driver cobalt chromium stent (Medtronic), with an excellent result in the main vessel (Figure 1B). Due to compromise of the side branch ostium with poor flow and associated chest discomfort, the side branch was wired using a Wizdom 0.014 inch guidewire (Cordis Corp., Miami, Florida), and the ostium was dilated with a 2.5 x 15 mm Sprinter balloon (Medtronic). Due to an unsatisfactory result in the side branch, the ostium was stented with 2.5 x 8 mm Taxus paclitaxeleluting stent (Boston Scientific), which was then reversecrushed with a 3.0 x 15 mm Sprinter balloon (Medtronic) in the main vessel. The side branch was rewired using a Pilot 50 0.014 inch guidewire (Guidant), and sequential high-pressure balloon dilatation of the side branch and main vessel were performed. Disruption of the left main origin was detected during the procedure and treated by direct stenting using a 3.5 x 24 mm Driver cobalt chromium stent (Medtronic).

While attempting to position the main vessel balloon after the reverse crush, difficulty in manipulating the main vessel guidewire was noted (Figures 1C–E). During attempts to retract the BMW wire (Guidant) positioned in the main vessel, it became apparent that the distal radio-opaque portion of the wire was fixed in the distal coronary artery. With continued retraction, there was subsequent unraveling and fracture of the guidewire. Careful inspection demonstrated that the proximal end of the unraveled wire extended into the stented segment of the left main coronary artery (Figure 1F).

Retrieval Technique. An 8 Fr Voda left guide catheter (Boston Scientific) was positioned in the left main coronary ostium; a larger lumen guide catheter was selected to facilitate removal of retrieved debris. Additional intra-arterial heparin was administered. Attempts using a single 0.014 inch Wizdom wire were unsuccessful. A triple wire technique was then chosen to optimize the likelihood of sufficient distal wire capture (Figure 2): adequate wire entanglement with multiple wires was felt to be important to allow retraction proximally past the multiple stented segments. Three Wizdom 0.014 inch guidewires (Cordis) were sequentially introduced into the diagonal branch. Care was taken to ensure the guidewires did not pass beneath the struts of the stents in the proximal vessel so as to ensure that the retrieved fragment could be easily removed without resulting in entrapment in the more proximal stented vessel. Each guidewire was rotated in a clockwise fashion while traversing past the fractured distal tip of the original wire designed to rotate around, and thus ensnare, the fractured wire. Rotation was performed while passing the wire from the proximal-to-distal components of the visible radio-opaque marker, which represented the most bulky and easily identifiable component of the fractured wire. After each of the 3 guidewires had been individually rotated distal to the fractured wire, all 3 wires were then rotated together to further entangle the fractured segment (Figure 3A). The entangled collection was then carefully extracted past the stented segments into the guide catheter (Figure 3B). Final angiography confirmed an excellent angiographic result, with no wire residua noted. The effectiveness of this technique in entangling the distal wire was apparent when the extracted debris was reviewed (Figure 4).

Discussion. Due to the increasingly complex nature of PCI, there is an associated risk of device dislodgement and fracture, despite advances in PCI technology. The incidence of device embolization and wire fracture remains low, and is reported to be 0.02% in patients undergoing PCI.⁴ Although uncommon, awareness of the methods for device extraction are essential for any interventional cardiologist performing such complex procedures. Retained debris may predispose to perforation, thrombosis and arrhythmia.¹¹

The mechanism for guidewire fracture is unclear in this case. The main vessel wire may be potentially impinged upon by the proximal end of the side branch stent during postdilatation of the side branch ostium after a reverse-crush procedure. This reinforces the need to protect the main vessel wire with a balloon positioned in the main vessel when postdilatation of the side branch is performed during the reverse-crush technique. Alternatively, use of the Culotte technique might have simplified the procedure when it became clear that the side branch required stenting, and might have potentially avoided this complication. Given the size difference between the main vessel and side branch, a reverse-crush technique was felt to more likely to render an optimal result in both branches.

Unraveling of a guidewire has been described in the setting of positioning a stent over a wire which had been positioned to protect a side branch during percutaneous management of a bifurcation stenosis.¹³ In this case, removal of the undeployed stent was sufficient to remove the unraveled wire. In our example, fracture and unraveling may have complicated wire fatigue due to positioning in a tortuous distal vessel during a long procedure. Upon careful retrospective review of the cineangiograms obtained during the procedure, it appeared that the wire fracture may have occurred prior to the reverse-crush procedure; the distal radio-opaque marker could be seen to be no longer moving in continuity with the proximal wire before the reverse-crush was performed. The effect of recurrent systolic compression upon the wire when positioned in the tortuous distal vessel may produce sufficient strain to result in wire fatigue and fracture.¹⁴ Given the increasingly complex nature of PCI, particularly when treating bifurcation lesions in tortuous vasculature, operators ought to be mindful of this possibility of wire fatigue, unraveling and fracture. This case demonstrates an elegant and simple method for extraction of a fractured guidewire.

Management options for retrieval of retained debris within the coronary artery vary depending upon the extent of retained material, the clinical status of the patient and the size, relevance and characteristics of the involved vessel. Successful conservative management of fractured angioplasty wires has been described, and appears appropriate for occluded or smaller distal vessels.⁴ Anticoagulation or antiplatelet agents are additionally used in this setting to prevent the subsequent development of thrombosis. Successful emergent surgery has been performed in cases of hemodynamic instability.²

Various methods for extraction of dislodged or fractured materials are available. Snares of various types have been utilized including gooseneck snares and loop snares,^10,15 which are more suitable for proximal, large-caliber vessels. The Amplatz Goose Neck Microsnare (Microneva, St. Paul, Minnesota) is designed for retrieval of debris in small vessels, witha diameter of 2–7 mm, which may be too large for retrieval in small, distal vessels, given the need to maintain a 1:1 ratio of snare-to-vessel diameter.¹⁶ Snares fashioned using standard angioplasty guidewires have also been used with success.¹⁷ Bioptomes have been employed in cases where the proximal segment of the retained device is adjacent to the coronary ostia.⁴ Use of a 2-angioplasty wire technique to retrieve a fractured distal balloon fragment has been described previously; in contrast to our example, in both cases the balloon remained positioned on the original guidewire and a second 0.014 inch guidewire was positioned distal to the retained balloon fragment. Rotation of the wires then formed a helix distal to the fractured balloon fragment, which then allowed retrieval of the balloon segment.^11,12 Additional alternative methods of fragment removal include use of distal protection devices. Both balloon occlusion devices and filter baskets have been utilized for retrieval of dislodged stents;^8,9,18 due to the inherent difficulties in using guidewires to snare an undeployed stent, distal protection devices with snares may be a particularly useful retrieval tool in this setting. Another method involves inflation of a balloon to trap a fractured guidewire against the wall of the guide catheter, with the balloon and wire then dragged proximally further into the guide.⁷ In this initial case description, the unraveled segment of guidewire remained partly within the guide catheter; this technique would be less practical for retrieval of material within the distal coronary arteries due to the likelihood of endothelial damage associated with retracting an inflated balloon into the guide catheter. Furthermore, one could anticipate that removal of the unit past a segment of a stented vessel would be difficult. Finally, stenting over the retained device is another option in a vessel of a suitable diameter when appropriate equipment can be delivered.¹⁹

While conservative therapy may be appropriate for small, occluded vessels, it was not felt to be appropriate in this setting due to the risk of propagation of thrombus to the proximal component of the unraveled guidewire. While emergent surgery may be appropriate in cases of profound ischemia and hemodynamic instability, repeat coronary artery bypass grafting in this patient would be associated with significant risk, including potential damage to the left internal mammary artery bypass graft. The small distal vessel diameter precluded the use of distal protection devices and would make delivery of snares problematic. Entrapment of the fractured segment and retraction into the guide using an angioplasty balloon would unlikely be successful, given the proximal stented section of vessel.

Conclusion. In this era of complex PCIs, fracture or dislodgement of equipment is an uncommon and unfortunate sequelae. Awareness of the suitability, advantages and limitations of the various described techniques for device retrieval, as well as the role of conservative management and emergent surgery, is critical. The use of 3 angioplasty guidewires to entangle the fractured guidewire is a simple and straightforward method, and is potentially a valuable tool in the management of these complications.

References

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