Retrieval of a fractured angioplasty guidewire after percutaneous retrograde revascularization of coronary chronic total occlusion

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Excerpt

A chronic total occlusion of the proximal right coronary artery (RCA) with contralateral collateralization by left anterior descending and thread-like continuous connection was recanalized electively in a 61-year-old patient suffering from angina pectoris Canadian Cardiovascular Society grade III. The collateral branch was tracked and entered with a Whisper MS (Abbott Vascular, Santa Clara, California, USA) and Corsair microcatheter (Asahi Intec, Aichi, Japan) and septal collateral passage was performed by a Sionblack (Asahi Intec). A change to Gaia 3 (Asahi Intec) was performed, which could be protrused from the middle to the proximal RCA. During the complex procedure, the end of the wire gets entangled in the heavily calcified vessel, twisted and broke after pulling (Fig. 1a, arrow).
Computed tomography angiography showed the residual broken guidewire in the RCA, with retrograde expansion to the ostium of the left coronary artery (Fig. 1b and c). Wire strings continued from the thoracic to the abdominal aorta with multiple loops and ends up in arteria intervertebralis cranial of the arteria renalis (Fig. 1d).
Subsequently, it was tried to catch the wire with a 20-mm loop-snare, which was used in a retrograde ‘hotwire technique’. Our chosen term ‘hotwire technique’ was inspired by a famous game of skill and coordination, which requires to guide the metal wand (snare loop) around the wire circuit (broken guidewire filament).
An Emerge balloon 3.0/15 mm (Boston Scientific, Marlborough, Minnesota, USA) was inflated, to jail the broken guidewire (Fig. 2a). Afterwards the snare was pulled with appropriate force and the wire teared of (hash). Finally, parts of the broken wire remained in situ in septal branches of left anterior descending and RCA, whereas no further wire parts were found in the left main trunk and the aorta (Fig. 1e and f). Twisted wire filaments could be visualized after retrieval (Fig. 2b).
A retained guidewire in the aorta might be complicated by thrombosis, emboli, or endocarditis and should be removed 1. The risk of guidewire fracture rate is increased in complex interventions with tortuous and calcified vessels such as chronic total occlusions. Retrieval can be attempted either with percutaneous techniques 2 or with surgery 3. However, retained fractured guidewires rarely leads to any clinical sequelae. For this instance, we have decided for a conservative approach due to lack of any cardiovascular symptoms and clinical stability.
The patient was discharged with recommendation of dual antiplatelet therapy with aspirin and ticagrelor and was free of clinical symptoms and thromboembolic events after a follow-up period of 6 months.

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