Case Report and Brief Review

Snare Retrieval of the Distal Tip of a Fractured Rotational Atherectomy Guidewire: Roping the Steer by Its Horns

Kirk Gavlick, MD and James C. Blankenship, MD
Kirk Gavlick, MD and James C. Blankenship, MD
Fractured coronary guidewire is a relatively uncommon complication of percutaneous coronary intervention. Numerous methods have been described for retrieval of these retained fragments from the coronary circulation. These methods have included snaring guidewires with pigtail catheters1,2 paired guidewires knotted together,3 Dotter basket snares,4 homemade wire loop snares,5,6 manufactured snares7 and retrieval forceps.8 In coronary arteries, snares typically capture the most proximal (fractured) end of the wire fragment. We report a case of a fractured rotational atherectomy coronary guidewire retained within a coronary artery where this was not feasible. A distal snaring technique was successful, illustrating the principle that identifying the most accessible part of the foreign body is critical to the success of a retrieval procedure. Case Report. A 70-year-old male with remote stenting of the left anterior descending coronary artery presented with exertional angina. Exercise sestamibi myocardial perfusion imaging showed a large, severe, reversible lateral perfusion defect. Diagnostic angiography demonstrated heavily calcified coronary arteries. The only significant lesions were in the circumflex which contained a 90% ostial stenosis and a 70% mid stenosis (Figure 1A). The ejection fraction was 65%, with no wall motion abnormalities. Because of lesion calcification, we proceeded with percutaneous transluminal rotational atherectomy of the ostial left circumflex coronary artery. Bivalirudin bolus and infusion were administered. A 0.009 inch Rotafloppy wire (Boston Scientific, Natick, Massachusetts) was passed through a 6 Fr CL4 guide catheter and across the proximal and mid-circumflex lesions. A 1.5 mm Rotablator® burr (Boston Scientific) was advanced into the left main coronary artery. Ablation runs at 180,000 rpm were performed without difficulty, keeping drops in rpm to less than 3,000, and run times less than 20 seconds. There were no problems with kinks or loops in the guidewire. After the fifth ablation run, the guiding catheter fell out of the left main coronary. As the guiding catheter was gently pulled into the left main over the atherectomy catheter and wire, the guidewire retracted freely but the tip remained in place in the circumflex obtuse marginal branch (Figure 1B). The Rotablator burr, guiding catheter, and wire were removed and examined. Compared to a new Rotafloppy guidewire, the fractured guidewire was missing the 3 cm radiodense 0.014 inch tip and approximately 4 cm of adjacent 0.009 inch wire. A 6 Fr Judkins left 5 guiding catheter (Boston Scientific) seated more securely in the left main coronary artery. A 0.014 extra-support coronary guidewire was positioned distal to the retained guidewire fragment. Angioplasty with a 2.0 x 12 mm Maverick™ balloon (Boston Scientific) inflated to 12 atm was performed at the ostial and mid-portion of the left circumflex coronary artery. A 0.014/300 cm Trooper™ Extra Support guidewire (Boston Scientific) was used in an unsuccessful attempt to intertwine and retract the retained fragment. A 2.5 x 15 mm Quantum™ Maverick™ OTW balloon (Boston Scientific) was positioned distally to the retained fragment, inflated to 2 atm, and withdrawn in an unsuccessful attempt to pull the fragment proximally (Figure 1C). A 4 mm Microvena snare catheter (ev3, Inc., Plymouth, Minnesota) was prepared. To facilitate passage of the snare catheter, the lesions in the mid- and ostial circumflex were dilated with 3.0 x 12 mm Quantum Maverick balloon (Boston Scientific, 12 atm). The snare catheter was passed over the 0.014/300 cm Trooper Extra support wire and positioned at the distal end of the guidewire fragment. The snare loop was deployed distal to the guidewire fragment. On the second attempt the snare captured the most distal portion of the retained wire fragment. With gentle tension on the snare loop, the snare catheter, loop and retained fragment were pulled into the guiding catheter and removed as an entire unit. The patient remained asymptomatic during this procedure. Stenting of the mid-circumflex coronary artery with a 2.5 x 20 Scimed Express2™ stent (Boston Scientific) over a 0.014/300 cm Trooper Extra Support wire was thwarted by heavy calcification and tortuosity of the proximal vessel. After changing the wire to a 0.014/300 cm ACS Hi-Torque Iron Man™ (Guidant Corp., Indianapolis, Indiana) and predilating (3.0 x 20 mm Quantum Maverick OTW Balloon, Boston Scientific), the same stent failed to cross, but a 2.5 x 18 mm AVE S660 (Medtronic, Inc., Santa Rosa, California) was successfully deployed at 16 atm. The ostial circumflex lesion was treated with the original 2.5 x 20 mm Scimed Express2 coronary stent at 16 atm. Final imaging showed residual 10% stenosis in the ostial circumflex and less than 0% stenosis in the mid-circumflex (Figure 1D). Serial creatine kinase and creatine kinase-MB enzymes were normal after the procedure. The patient was discharged the next day in good condition. The two pieces of the fractured guidewire laid end-to-end equaled the length of a new Rotafloppy wire. Discussion. This report describes the successful snaring of the distal tip of a retained wire fragment in a coronary artery. To our knowledge, this is the first such case reported. Previously reported snaring procedures have targeted the proximal end of the fractured wire at the point of fracture.3,5–7 This case illustrates two important points about retrieval of fractured intracoronary guidewires. First, extraction is easier when only the radiodense distal tip is retained in the coronary artery. In all reported cases of snares successfully removing intracoronary retained fragments, the fragment only included the radiodense tip. When the retained fragment includes proximal sections of radiolucent wire, the proximal wire may impede passage of rescue wires or balloons through the coronary artery or, as in our case, the proximal section of the wire may be too radiolucent to be seen or snared. Other creative retrieval techniques may be necessary to remove these wire fragments.3,9 A second point is that while most snaring attempts are aimed at the proximal “tail” of the wire fragment, it may be possible to snare the radiodense “head” of the fractured wire, much as a cowboy ropes a steer. The operator should identify and aim for the best target. If the “head” of the fragment is trapped in plaque, then the “tail” may offer the better target.3,5–7 If the radiolucency of the “tail” makes it invisible and the “head” is free, as in our patient, then the “head” may offer a better target for snaring. A Medline search identified 17 reports of 24 patients with retained fractured wires in coronary arteries, including 6 patients with fractured rotational atherectomy wires. Wire fracture was reported approximately twice yearly from the mid-1980s to the mid-1990s, but only twice since 1998. Improved construction of guidewires and increasing sophistication of operators have made guidewire fracture a rare problem. In our experience in over 3,000 interventions this was the first instance of wire fracture. Reports of extraction of fractured guidewires are a testimony to the ingenuity and creativity of interventionists. Solutions have included snaring guidewires with pigtail catheters,1,2 paired guidewires knotted together,3 Dotter basket snares,4 homemade wire loop snares,5,6 manufactured snares7 and retrieval forceps.8 Other techniques have included extracting guidewire fragments with intertwined guidewires,10 balloons inflated distally in the artery and dragged proximally9,11–13 or open heart surgery.14–21 Wire fragments were left in place in 7 patients without adverse sequelae.1,20,22 (We found no reports of adverse consequences from wire fragments left in coronary arteries.) Many cases of wire fracture occur when the distal end of the wire becomes trapped. In these cases the fracture usually occurs at the proximal end of the radiodense wire tip. In two cases, wire fracture proximal to the radiodense tip was attributed to grinding by the rotational atherectomy burr.9,23 This mechanism could not be invoked in our patient because the Rotablator burr never advanced closer than 3 cm to the point of guidewire fracture or closer than 10 cm to the end of the guidewire. A manufacturing flaw may have been responsible for our wire fracture. When the fractured wire extends out of the coronary ostium into the aorta, it may be successfully snared with a pigtail catheter, Amplatz catheter, Dotter basket, biopsy forceps1,2,4,24 or homemade snare.25 However, when a long segment of wire resides in the artery it may prevent passage of other catheters alongside the fractured segment and make retrieval more difficult.23,26 In cases where the retained fragment is entirely in the coronary artery, snaring has proved to be the most successful technique.3,5–7 In these cases, the snare has been passed over the proximal (fractured) end of the guidewire, analogous to a cowboy roping a steer by its hind legs. In our patient this was not possible because the 0.009 inch rotational atherectomy wire was radiolucent and could not be visualized in the coronary artery. However, the 0.014 inch radiodense distal tip of the wire appeared to be free in the coronary lumen. We were able to snare the most distal tip of the fractured wire, much as a cowboy would rope a steer by its horns. In summary, this case illustrates the general principle that successful snaring depends on identifying the part of the object that is most accessible and doing what is necessary to reach it. Currently available snares are capable of reaching far into distal coronary arteries to retrieve hardware.
References
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