Management of Guidewire Entrapment With Laser Atherectomy

J INVASIVE CARDIOL 2017;29(5):E61-E62.

Key words: laser atherectomy, percutaneous coronary intervention

A 62-year-old man was referred for percutaneous coronary intervention (PCI) of a circumflex lesion (Figure 1A). He had received a left anterior descending (LAD) coronary artery stent that was assessed using intravascular ultrasound. The LAD guidewire became entangled in the LAD stent and could not be removed (Figures 1B and 1C). The left main was engaged with a second guide catheter using the “ping-pong” technique, followed by multiple balloon dilations, microcatheter advancement (Figure 1D), and finally laser atherectomy with a 0.9 mm laser catheter (Spectranetics) using pulse frequency of 40 Hz and maximal fluency of 60 mJ/mm² in attempts to free the wire; however, all attempts failed (Figure 1E). The guidewire fractured, but intravascular ultrasound confirmed that no wire fragment protruded into the aorta (Figures 1F and 2A); hence, no attempts were made to snare the wire. The patient became hypotensive, requiring stenting of the circumflex with two 2.75 x 12 mm drug-eluting stents (Figures 2B and 2C), followed by left main stenting with a 3.0 x 28 mm drug-eluting stent that covered the guidewire fragment (Figure 2D). After postdilation with a 3.5 x 8 mm non-compliant balloon, an excellent result was achieved by angiography, intravascular ultrasound, and optical coherence tomography (Figures 2E and 2F). The patient had uneventful recovery, and indefinite dual-antiplatelet therapy was recommended.  

Entrapment and fracture of a guidewire occurs in approximately 0.1%-0.2% of PCIs.¹ Caution should be used when wiring through coronary stents to minimize the risk for wire entrapment. In case of guidewire fracture, there are three potential therapeutic options: percutaneous removal, surgical retrieval, or conservative treatment leaving the fractured fragment in situ.^1,2 Wire fracture can be successfully treated with stent implantation over the wire fragment,³ provided the fragment does not protrude into the aorta. Use of the laser likely contributed to the focal fracture of the entangled guidewire preventing unraveling of the guidewire and protrusion into the aorta, which would have necessitated cardiac surgery for removal.    

References

1.    Al-Moghairi AM, Al-Amri HS. Management of retained intervention guide-wire: a literature review. Curr Cardiol Rev. 2013;9:260-266.

2.    Danek BA, Karatasakis A, Brilakis ES. Consequences and treatment of guidewire entrapment and fracture during percutaneous coronary intervention. Cardiovasc Revasc Med. 2016;17:129-133.

3.    van Gaal WJ, Porto I, Banning AP. Guidewire fracture with retained filament in the LAD and aorta. Int J Cardiol. 2006;112:e9-e11.

From the ¹VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas; ²Division of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary; and ³Minneapolis Heart Institute, Minneapolis, Minnesota.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Banerjee reports research grants from Gilead and the Medicines Company; consultant/speaker honoraria from Covidien and Medtronic; ownership in MDCare Global (spouse); intellectual property in HygeiaTel. Dr Brilakis reports consulting/speaker honoraria from Abbott Vascular, Asahi Intecc, Cardinal Health, Elsevier, GE Healthcare, and St Jude Medical; research support from Boston Scientific and InfraRedx; spouse is employee of Medtronic. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted September 13, 2016, provisional acceptance given September 20 2016, final version accepted October 5, 2016.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, MN 55407. Email: esbrilakis@gmail.com