Extraction of an Entangled Coronary Guidewire Using the Balloon Trapping Technique

OVERVIEW

A 74-year-old man who previously underwent percutaneous coronary intervention (PCI) for a right coronary non-ST-segment elevation myocardial infarction was scheduled for physiology-guided PCI to a left main stem (LMS)/left anterior descending (LAD) lesion (Supplementary video 1).

Pressure wire assessment of the LMS/LAD identified an instantaneous wave-free ratio of 0.80. Circumferential calcification was observed with intravascular ultrasound (IVUS) (Figure 1A), and provisional LMS-LAD stenting was planned. Wires were placed in the intermediate and diagonal vessels, and the calcific LAD lesion was prepared using 2.5 mm cutting and 3.5 mm intravascular lithotripsy balloons. Overlapping drug-eluting stents were deployed (Figure 1B), jailing the diagonal wire. The stents were post-dilated (Figure 1C), and a final LAD-left circumflex kissing balloon inflation was undertaken. IVUS confirmed adequately opposed stents, and removal of the guidewires was attempted.

Although the intermediate vessel wire was removed, the jailed diagonal wire was thoroughly trapped and could not be extracted through conventional techniques. Once the operator was aware of the entrapment mechanism (jailing of the diagonal wire beneath the 2 layers of stents in the LAD with probable wire deformation between the stent struts [Figure 1D]), additional negative traction was avoided, otherwise the side-branch wire could completely deform or fracture. Instead, to exert efficient force to extract the wire, a 2.5 mm noncompliant balloon was inflated within the distal tip of the guide catheter, thereby trapping the wires in a proximal position (Figure 1E,F). The guide catheter was then pulled to extract the jailed wire in the diagonal branch, which was successfully withdrawn (Figure 1G, Supplementary video 2), with no angiographic deformation of the stents (Figure 1H, Supplementary video 3).

Herein, we highlight the value of the balloon trapping technique to facilitate the safe extraction of an inadvertently entrapped guidewire in bifurcation PCI. Jailed side branch wires should be removed before implantation of additional stents, especially in cases of overlapping stents where the side-branch wire is jailed beneath multiple strut layers.

Affiliations and Disclosures

From ¹Interventional Cardiology Unit, Hospital Clínico San Carlos IDISSC, Universidad Complutense de Madrid, Calle del Prof Martín Lagos, 28040, Madrid, Spain

Disclosures: J.E. reports speaker advisory board member for Abbott/Philips, consultancy fees from Boston Scientific and Medis. No analytic data were included in this case report. Angiographic and haemodynamic data can be provided upon request.

Address for Correspondence: Hernán Mejía-Rentería MD PhD, Interventional Cardiology Unit, Hospital Clínico San Carlos IDISSC, Calle del Prof Martín Lagos, 28040, Madrid, Spain, Email: hmejiarenteria@gmail.com