Fracture of coronary guidewire during rotational atherectomy with coronary perforation and tamponade

Consequences and management of guidewire fracture-entrapment in the left circumflex artery: a case report

Background

Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%.

Case summary

A 52-year-old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the left main/left ascending artery area, likely caused by the coronary snare. These interventions were crucial in stabilizing the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up.

Discussion

Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal; however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.

Rotational atherectomy to left circumflex ostial lesions: tips and tricks

Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

The Task Force on Rotational Atherectomy of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed the expert consensus document to summarize the techniques and evidences regarding rotational atherectomy (RA) in 2020. Because the revascularization strategy to severely calcified lesions is the hottest topic in contemporary percutaneous coronary intervention (PCI), many evidences related to RA have been published since 2020. Latest advancements have been incorporated in this updated expert consensus document.

Incidence and Mechanisms of Coronary Perforations during Rotational Atherectomy in Modern Practice

Objective

Heavy calcifications remain formidable challenges to PCI, even for well-experienced operators. However, rotational atherectomy (RA)-induced coronary perforations (CPs) still could not be obviated. This study was to explore incidence and mechanisms of RA-induced CP in real-world practice. Knowing why CPs occur in RA should help operators avert such mishaps.

Method

Patients who received coronary RA from April 2010 to December 2019 with keywords related to perforations were retrieved from database. The procedure details, angiography, and clinical information were reviewed in detail.

Results

A total of 479 RAs were performed with 11 perforations in 10 procedures among 9 patients documented. The incidence of RA-induced CP was 2.1%. The RA vessels were distributed in different territories, including first diagonal branch. Most CPs could be treated conservatively, but prolonged profound shock predisposed to poor outcome. CPs caused by rotawire tip occurred in 18.2% of cases, inappropriately sized burrs in 18.2% of cases, and rotawire damage with subsequent transection and perforation in another 18.2% of cases. A total of 5 (45.5%) perforations were caused by unintended and unnoticed bias cutting into noncalcified plaques (4, 36.4%) or through calcified vessel wall (1, 9.1%). The mechanisms for certain CPs were unique and illustrated in diagrams.

Conclusion

CPs due to RA occur in certain percentage of patients. The mechanisms for CPs are diverse. Wire damage with subsequent transection could occur due to inappropriately repetitive burr stress on the wire body. A significant portion was due to unintended and unnoticed bias cutting into noncalcified plaque or through calcified vessel wall.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics

Rotational atherectomy (RA) has been widely used for percutaneous coronary intervention (PCI) to severely calcified lesions. As compared to other countries, RA in Japan has uniquely developed with the aid of greater usage of intravascular imaging devices such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS has been used to understand the guidewire bias and to decide appropriate burr sizes during RA, whereas OCT can also provide the thickness of calcification. Owing to such abundant experiences, Japanese RA operators modified RA techniques and reported unique evidences regarding RA. The Task Force on Rotational Atherectomy of the J apanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document to summarize the contemporary techniques and evidences regarding RA.

Rotational atherectomy and same day discharge: Safety and growth from a national perspective

OBJECTIVES

We explore whether same day discharge (SDD) is a feasible and safe practice following rotational atherectomy (ROTA) treatment during elective percutaneous coronary intervention (PCI), and examine which baseline characteristics are independently associated with SDD.

BACKGROUND

SDD following elective ROTA PCI is not recommended as per the recent SCAI consensus. However, reports show it is practiced and no previous study has evaluated its safety and feasibility.

METHODS

Our dataset included 4,591 patients undergoing elective ROTA PCI in England & Wales within an 8-years period. Independent associations with SDD were quantified via a multiple logistic regression model and the BCIS 30-day mortality risk model was used to evaluate the safety of SDD.

RESULTS

The majority of elective ROTA PCI cases remain at the hospital for overnight (ON) observation, although SDD rates increased substantially from 6.7% in 2007 to 35.5% in 2014. The use of glycoprotein IIb/IIIa antagonists, Q wave AMI, left main PCI and valvular heart disease were independently associated with ON, while patients operated underwent transradial PCI were more likely to be SDD (OR = 1.77, 95% CI [1.45-2.15]). Over the study period, observed mortality rates were not significantly higher than those expected from the BCIS risk model.

CONCLUSIONS

Our findings did not show superiority of the ON strategy over SDD for higher risk cases undergoing elective ROTA PCI, in terms of 30-day mortality. This is the first study to examine the safety of SDD after elective ROTA PCI and more should follow.

Lost in circulation

BACKGROUND

Device complications in complex percutaneous coronary interventions are rare but potentially deadly. Surgical removal is often required. However, an evaluation of surgical therapy beyond case reports is practically not existent.

METHODS

We prospectively followed all cases of retained guide wires and/or other devices referred to us for surgical removal between 2015 and 2019 and retrospectively searched our database for such cases between 2010 and 2014.

RESULTS

From 2015 on, eight cases were referred for surgical removal from six different cardiology departments. In the 5 years before, there was not a single case. Six patients were operated emergently. Patients were 60.5 ± 5.42 years old, overweight (body mass index 30.1 ± 3.77) and except for one case (left ventricular-assist device) showed preserved ejection fraction (EF) (mean EF 57 ± 18.01). The retained devices were mostly located in the right coronary artery (50%), followed by the circumflex artery (37.5%) and diagonal branch (12.5%). The devices were remnants of guide wires (n = 4), balloon catheters (n = 3), and in one case a rotablator. Full sternotomy was performed in six patients and two received a left-sided minithoracotomy (n = 2). The operations were performed on-pump in five (62.5%) and off-pump in three patients. Complete extraction of the foreign bodies was possible in all patients. Two patients died; one in unrelated multiorgan failure and one due to retained-device-related right heart failure. The other patients survived and had uneventful postoperative courses.

CONCLUSIONS

Retained foreign bodies from cardiac interventions can be completely removed surgically using individualized approaches. There appears to be a trend toward a rising incidence of such interventional complications.

A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention

Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.

Incidence and Determinants of Complications in Rotational Atherectomy

Background—

The usage of rotational atherectomy (RA) is growing in the current percutaneous coronary intervention (PCI) because of the expansion of PCI indication to more complex lesions. However, the complications after RA have been linked to procedure-related morbidity and mortality. The purpose of this study was to investigate the incidence and determinants of complications in RA using a large nationwide registration system in Japan (J-PCI).

Methods and Results—

The primary composite outcome of this study was defined as the occurrence of in-hospital death, cardiac tamponade, and emergent surgery after RA. A total of 13 335 RA cases (3.2% of registered PCI cases) were analyzed. The composite outcome was observed in 175 cases (1.31%) and included 80 in-hospital deaths (0.60%), 86 tamponades (0.64%), and 24 emergent surgeries (0.18%). The clinical variables associated with occurrence of the composite outcome were age (odds ratio [OR] 1.03 per unit increment, 95% confidence interval [CI] 1.02–1.05), impaired kidney function (OR 1.59, 95% CI 1.15–2.19), previous myocardial infarction (OR 1.69, 95% CI 1.21–2.35), emergent PCI (OR 4.02, 95% CI 1.66–8.27), and triple-vessel disease (versus single-vessel disease: OR 2.17, 95% CI 1.43–3.28). Notably, institutional volume of RA cases was inversely associated with the composite outcomes (high- versus low-volume institution: OR 0.56, 95% CI 0.36–0.89).

Conclusions—

The reported incidence of important procedure-related complication rate was 1.3%, with each component ranging between 0.2% and 0.6% in J-PCI. Its determinants were both patient related (age, impaired kidney function, and previous myocardial infarction) and procedure related (emergent procedures, number of diseased vessels, and institutional volume of RA).

Management of retained intervention guide-wire: a literature review

Percutaneous coronary angioplasty is increasingly employed in the treatment of patients with complex coronary artery disease.

Different steerable guide wires used to open occluded vessel and facilitate balloon and stent deployment. However, the guide-wire itself is not without hazard: it may perforate or dissect the vessel, but fracture or entrapment is uncommon. Its management depends on the clinical situation of the patient, as well as the position and length of the remnant.

In this review we discuss the angioplasty guide-wire fracture and entrapment risk factors, potential risks and management.

Retrieval of Broken Export Catheter during Primary Angioplasty

Broken catheter fragments in a coronary artery during percutaneous coronary interventions although uncommon can potentially result in life-threatening consequences from the attended embolization, thrombus formation, and perforation. We report an unusual complication of a broken export catheter during primary angioplasty, which was successfully managed by inflated balloon-mediated retrieval technique.

Fatal subacute stent thrombosis induced by guidewire fracture with retained filaments in the coronary artery

During percutaneous coronary intervention, guidewire fractures are very exceptionally encountered in medical practice, but can cause fatal complications such as intracoronary thrombus formation, embolization and perforation. Removal of the remnant segments of guidewire is important for the prognosis. There are several methods being recommended for the treatment of fractured guidewire remnants. However, the best treatment of remnant guidewire filament is still unclear. Herein, we present a case where we did not completely remove remnant guidewire filaments that caused fatal coronary thrombosis.

Mechanism and management of burr entrapment: A nightmare of interventional cardiologists

Entrapment of the burr within calcified lesion is an uncommon, but serious complication during rotational atherectomy and usually needs surgical retrieval. We report a case series of this complication and also review the possible mechanisms, such as kokesi phenomenon or insufficient pecking motion with decreased rotational speed. We also review the potential techniques ever proposed to rescue this complication percutaneously, including simple manual traction, balloon dilation to release the trap, snaring the burr as distal as possible for forceful local traction and wedging the burr with a child catheter to facilitate retrieval. Gentle pecking motion of the burr for sufficient ablation and shortening the run less than 15 s may avoid such complications. Interventional cardiologists using the rotablator should be familiar with the tips and tricks to avoid and rescue this complication.

A case of fractured guide wire perforating the coronary artery and ascending aorta during percutaneous coronary intervention

We experienced a rare and serious case of fractured hydrophilic guide wire necessitating surgical intervention during percutaneous coronary intervention (PCI) for a tortuous and calcified stenosis in the proximal right coronary artery. An 85-year-old female presented to our hospital and was diagnosed as having unstable angina. A 0.014 in. hydrophilic guide wire (HI-TORQUE WHISPER MS Guide Wire™, Abbott Vascular, Abbott Park, IL, USA) was fractured during PCI trying to pass a microcatheter Corsair™ (ASAHI INTEC, Seto, Japan). During the procedure to retrieve the retained guide wire, the distal segment of the fractured guide wire penetrated the atherosclerotic coronary wall and ascending aorta unexpectedly. The surgical procedure could be performed successfully by extracting the fractured guide wire segments and stopping the bleeding. The edge of a hydrophilic guide wire that is fractured by friction between the microcatheter and guide wire is extremely sharp and can perforate both the atherosclerotic coronary vessel wall and aortic wall. Caution should be exercised when using such a device in combination with a polymer-jacketed wire at an acute angulated and calcified lesion. <Learning objective: Guide wires are the most common devices for interventional cardiologists. Guide wire fracture is a rare complication, but cardiologists should be well informed about it. This case report presents a detailed situation of hydrophilic guide wire fracture and penetration of coronary artery and even the aorta and discusses the mechanism.>.

Comparison of frequency of complications with on-label versus off-label use of rotational atherectomy

Although rotational atherectomy (RA) is used for complex lesions in percutaneous coronary intervention, there are several contraindications and precautions. The purpose of our study was to compare complications between off-label and on-label use of RA. We identified 250 consecutive patients who underwent RA. Off-label characteristics included saphenous vein graft lesions, presence of thrombus, unprotected left main stenosis, coronary artery dissection, acute myocardial infarction (MI), left ventricular dysfunction, 3-vessel disease, long lesion (≥ 25 mm), or angulated lesion (≥ 45°). Patients who had ≥ 1 off-label characteristic were assigned to the off-label group (156 patients), and patients who had no off-label characteristics were assigned to the on-label group (94 patients). Occurrence of slow flow or periprocedural MI in the off-label group was higher than that in the on-label group (slow flow 30% vs 18%, p = 0.06; MI 8.8% vs 2.1%, p = 0.04), whereas severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups. In conclusion, compared to the on-label group, the off-label group had a higher incidence of slow flow and periprocedural MI. Severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups.

Left main approach for retrieval of retained guidewire fragment

Entrapment and detachment of guidewire fractures during percutaneous coronary intervention (PCI) are very rare, but can lead to life-threatening complications such as embolization, thrombus formation, and perforation. Surgical extraction of the remnant fragments is recommended if the percutaneous retrieval is not possible. We present a case of remnant guidewire into the left anterior descending artery (LAD) and aorta that led to acute coronary thrombosis following primary angioplasty. Surgical retrieval was possible only through a left main (LM) approach.

A case of guide wire fracture with remnant filaments in the left anterior descending coronary artery and aorta

Guide wire fractures during percutaneous coronary intervention (PCI) are very rare, but when they do occur they may lead to life-threatening complications, such as embolization, thrombus formation and perforation. In cases when percutaneous retrieval has failed, surgical extraction of the remnant fragments is recommended. We present a case of remnant guide wire filaments that remained in place without complications, over a one-year clinical follow up period.

Coronary guidewire circumcision during use of a Gopher support catheter: potential adverse interaction with polymer-jacketed wire design

Support catheters with a threaded, distal tip may be useful for crossing recalcitrant coronary lesions. The interaction between the Gopher support catheter and polymer-coated coronary guidewires may, however, result in circumferential stripping of polymer from the guidewire, with resulting wire damage or fracture. We report two cases of polymer-coated guidewire damage with use of a Gopher support catheter, suggesting that these two devices should not be used together.