Clinical Images

Guidewire Entrapment during Jailed Wire Technique

Alpay T. Sezgin, MD, Hakan Gullu, MD, Necip Ermis, MD
Alpay T. Sezgin, MD, Hakan Gullu, MD, Necip Ermis, MD
Several techniques are used to treat coronary bifurcation lesions. One of the commonly used techniques is the jailed wire technique, which is performed by inserting two guidewires into both the main and side branches of a coronary artery. When the main branch is stented, the side branch wire is jailed between the stent and the wall of the proximal main branch. One difficulty with the technique is wire withdrawal. There are no reports in the literature describing a broken jailed wire between two overlapping stents. Case Presentation. A 72-year-old male had undergone a coronary angioplasty procedure and a 3.5 x 10 mm Lenkton stent (Biotronik GmbH & Co., Berlin, Germany) was deployed in his proximal LAD 6 months prior to his admission. The patient was admitted due to class III angina pectoris even though he was on optimal anti-anginal medication. He underwent coronary angiography. A 7 Fr sheath was placed in the right femoral artery. A 7 Fr Judkins 4 guiding catheter (Medtronic, Inc., Minneapolis, Minnesota) was engaged in the left coronary ostium. Coronary angiography revealed 80% in-stent restenosis that extended to the distal *part of the first diagonal branch, which also had 80% ostial stenosis (Figure 1). We decided to perform Type-B treatment for the bifurcation lesion (stenting of the main branch followed by provisional stenting of the side branch) using the jailed wire technique. Two 0.014 inch floppy guidewires (ATW, Cordis Corp., Miami, Florida) were inserted into both the LAD and diagonal branches of the bifurcation. A 2.5 x 10 mm Sprinter balloon (Biotronik) was used to predilate the diagonal lesion (Figure 2). Next, a 3.5 x 24 mm Taxus® stent (Boston Scientific Corp., Natick, Massachusetts) was deployed across the ostium of the diagonal branch (Figure 3). After deploying the stent in the main branch, the wire in the main branch (LAD) was pulled back and reinserted into the diagonal branch. However, the jailed wire in the diagonal artery could not be pulled back because the floppy tip of the wire was trapped between two stents. Several attempts to pull the jailed wire back failed, and the floppy tip of the wire was broken, remaining between the two overlapping stents (Figure 4). In our opinion, the wire in the diagonal artery was entrapped between two stents at the proximal to the diagonal branch, therefore, we could *not pull back the entire wire. We did not make any further attempts to remove the broken wire because it was stable in its location. The patient remains asymptomatic at one-year follow up on beta-blocker, clopidogrel and aspirin therapy, and has fully returned to his previous activities. Discussion Ever since coronary angioplasty was first undertaken, the treatment of coronary bifurcation lesions has posed technical problems.1 Numerous techniques of stent deployment have been described for bifurcation lesions.1–5 Type-B treatment of a bifurcation lesion consists of stenting the main branch, followed by provisional stenting of the side branch at the ostium level through the struts of the main branch stent. The jailed wire technique is used in Type-B treatment. At the beginning of the treatment, two wires are inserted, both into the main and side branches. During deployment of the main branch stent, the side branch wire is jailed between the stent and the wall of the proximal main branch. Most difficulties with the jailed wire technique arise during withdrawal of the jailed wire.6 Recently, Louvard et al reported four incidences of distal rupture of the jailed wire out of several hundred cases.6 They reported that these ruptures always occurred when hydrophilic wires were used and suggested avoiding their use as jailed wires. In our case, we used an ATW steerable floppy guidewire instead of a hydrophilic wire as the jailed wire. Thus the problem was probably not due to the type of wire. We believe that the wire was broken because it was jailed between the two overlapping stents. Fractured coronary guidewire is a relatively uncommon complication of percutaneous coronary intervention. Numerous methods have been described for the retrieval of these retained fragments from the coronary circulation.7 These methods have included snaring guidewires with pigtail catheters,8,9 paired guidewires knotted together,10 Dotter basket snares,11 homemade wire loop snares,12,13 manufactured snares14 and retrieval forceps.15 In our case we did not attempt to remove the broken wire because it remained between overlapping stents and the wire fragment was left in place. We found no reports of adverse consequences from wire fragments left in coronary arteries. Since drug-eluting stents have been increasingly used for the treatment of in-stent restenosis in recent years, Type-B treatment (main branch stenting followed by provisional side branch stenting) should be performed cautiously against a broken wire when deploying a stent to treat in-stent restenosis covering a side branch. In such circumstances, Type-A treatment (side branch stenting followed by main branch stenting covering the ostium of the side branch) is preferable.
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