Journal of Invasive Cardiology

ABSTRACT: We present the first case reported of fracture of a coronary guidewire during thrombectomy of a massive thrombus in a recently occluded coronary bypass graft with the recently developed atherectomy catheter X-Sizer. The thrombus was successfully aspirated without distal embolisation and the guidewire fragment was trapped in the graft after covering with a coronary stent. Possible reasons for this unusual complication of X-Sizer are discussed.

J INVAS CARDIOL 2004;16:263–265
Key words: guidewire fracture, angioplasty complications, thrombectomy

Percutaneous coronary intervention (PCI) to thrombus-containing lesions is associated with a high risk of periprocedural complications. Distal embolism, no reflow and abrupt closure develop frequently and are associated with a high rate of myocardial infarction (MI) and mortality.¹

The treatment of this type of lesion includes pharmacological measures and mechanical devices. However, the most appropriate strategy has yet to be established. Recently, the X-Sizer device has been added to the arsenal of treatments available for thrombotic lesions. This is a new atherectomy catheter designed to extract atherosclerotic material and thrombus from coronary vessels. The initial experience with this tool appears to be favorable but it is still in a period of evaluation.^2–5 The clinical benefit should be more clearly established and the associated complications further recognized. We report the first case of guidewire fracture associated with the use of the X-Sizer device during PCI to a coronary graft.

Case Report. An 86-year-old male patient was hospitalized with non ST-elevation myocardial infarction and referred for heart catheterization. He had a long history of coronary artery disease, having suffered an inferior wall MI 20 years previously and underwent coronary bypass graft surgery 10 years previously. Five years prior to the current admission, he was catheterized. The internal mammary artery graft (IMA) to the left anterior descending artery (LAD) as well as the saphenous vein grafts (SVG) to the posterior descending artery (PDA) and the diagonal branch (D1) were patent. A saphenous vein graft to the obtuse marginal branch was found occluded. He was treated conservatively and was fine until a week before the current admission. He developed unstable angina and was hospitalized with prolonged chest pain at rest, with new inverted T waves in the precordial and inferior leads of the electrocardiogram. The troponin I level was elevated ( 2 mcg/ml ; normal value: < 0.7 mcg/ml) and a non Q-wave MI was diagnosed. He had recurrent rest angina despite full medical treatment and underwent heart catheterization. Complete occlusion of the proximal LAD and right coronary artery (RCA) as well as severe stenosis of the left main supplying a large left circumflex artery (CX) were demonstrated. The IMA and SVG to PDA were patent.