Broken guidewire during percutaneous transluminal coronary angioplasty retrieved properly and nightmare became a good lesson and experience

Sudeb Mukherjee; Kaushik Paul

doi:10.4103/jicc.jicc_32_21

CASE REPORT

Year : 2022 | Volume : 12 | Issue : 3 | Page : 143-145

Broken guidewire during percutaneous transluminal coronary angioplasty retrieved properly and nightmare became a good lesson and experience

Sudeb Mukherjee¹, Kaushik Paul²
¹ Department of Cardiology, AMRI Hospital, Kolkata, West Bengal, India
² Department of Cardiology, Institute of Post Graduate Medical Examination and Research, Kolkata, West Bengal, India

Date of Submission	26-May-2022
Date of Decision	01-Jun-2022
Date of Acceptance	15-Jun-2022
Date of Web Publication	14-Sep-2022

Correspondence Address:
Dr. Sudeb Mukherjee
4/28 A, Jadavgarh, Dr. B. C. Roy Road, Kolkata - 700 078, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicc.jicc_32_21

Abstract

Percutaneous transluminal coronary angioplasty is associated with less complications compared to the open surgical technique. Fractured guidewire inside coronary arteries is not common during the procedure. It should be removed with proper technique. Nonremoval of such fractured wire may pose several complications. Different techniques can be used to remove such fractured wires. Here, we have reported a case of such incidence and its removal successfully percutaneous safely.

Keywords: Guidewire, percutaneous transluminal coronary angioplasty, snare

How to cite this article:
Mukherjee S, Paul K. Broken guidewire during percutaneous transluminal coronary angioplasty retrieved properly and nightmare became a good lesson and experience. J Indian coll cardiol 2022;12:143-5

How to cite this URL:
Mukherjee S, Paul K. Broken guidewire during percutaneous transluminal coronary angioplasty retrieved properly and nightmare became a good lesson and experience. J Indian coll cardiol [serial online] 2022 [cited 2023 Feb 8];12:143-5. Available from: https://www.joicc.org/text.asp?2022/12/3/143/356061

Introduction

Percutaneous transluminal coronary angioplasty (PTCA) has a very fascinating history. Over the last two decades, the PTCA procedure has been evolved with the help of advanced technical support. The basic technical aspect of wiring the vessel remains the same from the very beginning. Taking a balloon over the wire and inflating it with a pressure system is a very crucial step during PTCA. Complications of breaking the wire during such a procedure are not very rare. It poses significant challenges to remove such broken wire from the lumina of arteries. Inability to do so may result in a catastrophe that includes restenosis, embolism, perforation, new myocardial infarction, and eventually death. Proper technique and expertise are very much needed to remove such broken wire safely and to complete the procedure of PTCA. There are reports in the medical literature of such fractured wire inside coronary arteries and its removal sometimes with complications that includes stent recoiling, vessel injury, and requirement of open-heart surgery. Here, we have reported one such incidence of the broken wire during PTCA which was removed percutaneously successfully and safely.

Case Report

A 54-year-old male was admitted with chest pain on exertion (CCS III) for the last several months. He was Type 2 diabetic controlled with medications. A coronary angiogram was done which revealed double vessel disease with involvement of the right coronary artery and left anterior descending artery (LAD). PTCA with DES stent was planned. The procedure of PTCA to LAD started with the right radial artery route. After engagement with EBU 6F (3.5) run through floppy was taken into LAD. It crossed the lesion in the midpart of LAD. Tortuosity of the midpart of LAD poses some difficulty in advancing the wire. However, the wire was taken up to the apex after crossing the lesion. Predilatation was done with a short balloon of 2 mm × 10 mm to inflate the diseased part. After inflation was done successfully, it was taken out. A dye shot was taken postpredilatation and it was found that floppy wire was broken from distally and lying into the distal part of LAD [Figure 1]. It was moving and slowly migrating toward the apex with contraction of the heart [Figure 2]. The patient had no complaint and he was hemodynamically stable without any new electrocardiogram changes. An immediate decision to remove the broken wire was taken. A coronary snare was taken and passed into LAD. After several attempts, the detached broken part of the floppy wire was grasped with the snare and removed [Figure 3], [Figure 4], [Figure 5]. Next of that, the procedure was completed successfully.

Figure 1: Broken guidewire in the mid to distal segment of LAD. LAD: Left anterior descending

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Figure 2: The broken tip of the guidewire moving distally within LAD. LAD: Left anterior descending

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Figure 3: Retrieval approach to broken guidewire by microcatheter and snare

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Figure 4: Retrieval of the broken part of the guidewire through the coronary snare

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Figure 5: Broken wire removed by the snare

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Discussion

The incidence of broken or retained PCI equipment is about 0.1%–0.8% in the literature.^[1] Entrapment, excessive torquing, forceful traction of the guidewires, fibrous calcified plaque, arterial spasm, inadvertent handling of the catheter, and manufacturing flaws are usually responsible factors. The use of rotablation technique, intravascular ultrasound, and optical coherence tomography has also been associated with this type of complication.^[2] Fractured guidewire if remained inside arteries may increase the risk of embolic manifestations, rupture, dissection, and new infarction due to closure of the distal lumen.^[3],[4] The basic structure of a guidewire is (1) central core, (2) spring coil, and (3) coating. The central core is usually composed of stainless steel, nitinol, or in combination. Spring coil is made of either platinum or tungsten. The coating may be hydrophilic or hydrophobic. The weakest part of the guidewire is the junction between the flexible 3-cm tip and the remainder of the guidewire. It is usually the common broken site. In this case, a fracture occurred in the distal part. The reason may be due to distal tortuosity and inherent weakness of the wire. The fractured retained wire can be removed by a different technique. The broken part can be retrieved by snare, wire intertwining, balloon support, mobilizing, and pressing the broken fragment to the wall of the distal part of the artery, triple wire technique, or leave the wire alone if it is in an insignificant size distal vessel or branch and finally with open surgery.^[5],[6] In our case, the Amplatz Goose Neck snare catheter was used for the removal of the broken guidewire, and the procedure was completed successfully. Removal of such fractured wire may be associated with several complications that have been reported in the literature. In our case, we did it successfully percutaneously, and safely. Moreover, ultimately nightmare became an enormous teaching experience for the whole team.

Conclusion

Selection and proper inspection of wire especially the distal tip, radiopaque part, and the junction part is a very important part of the procedure
Accidents can happen but one must not panic
Coronary snare can solve the problem, however proper expertise and experience are very much needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260-4.
2.	Yedlicka JW Jr., Carlson JE, Hunter DW, Castañeda-Zúñiga WR, Amplatz K. Nitinol gooseneck snare for removal of foreign bodies: Experimental study and clinical evaluation. Radiology 1991;178:691-3.
3.	Vrolix M, Vanhaecke J, Piessens J, De Geest H. An unusual case of guide wire fracture during percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1988;15:99-102.
4.	Balbi M, Bezante GP, Brunelli C, Rollando D. Guide wire fracture during percutaneous transluminal coronary angioplasty: Possible causes and management. Interact Cardiovasc Thorac Surg 2010;10:992-4.
5.	López-Mínguez JR, Dávila E, Doblado M, Merchán A, González R, Alonso F. Rupture and intracoronary entrapment of an angioplasty guidewire with the X-Sizer thromboatherectomy catheter during rescue angioplasty. Rev Esp Cardiol 2004;57:180-3.
6.	Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol 2007;19:E230-4.