INTRODUCTION:Percutaneous coronary intervention (PCI) is an established procedure for treatment of ischemic heart disease. However, acute complications may occur in as many as 10% of these procedures. Entrapment of a guide wire is an uncommon complication that may cause occlusion of the coronary artery, and may require percutaneous or surgical intervention, depending on the clinical situation. We report a case of guide wire entrapment during PCI of left anterior descending (LAD) stenosis using retrograde approach via a saphenous venous graft (SVG), which required surgical extraction and repair of LAD using a venous graft.
CASE PRESENTATION:A 57 year old male was admitted with Canadian Cardiovascular Society Class IV angina. He had coronary artery bypass graft (CABG) surgery 10 years ago with SVG to distal LAD and obtuse marginal-1 (OM-1). Post-operative course was complicated by respiratory failure requiring prolonged mechanical ventilation. Since CABG, he had multiple PCI’s following his initial CABG for chest pain syndrome. Additional past medical history was relevant for diabetes mellitus, atrial fibrillation and chronic renal insufficiency. During the index hospitalization for severe angina, coronary angiography revealed proliferative in-stent restenosis leading to chronic total occlusion (CTO) in the proximal LAD (Figure 1A) and a 99% stenosis in the LAD distal to SVG anastomotic site (Figure 1B). The sephanous vein graft to obtuse marginal-1 was patent. A decision was made to attempt to open the distal LAD stenosis via the SVG. A Pilot-150 guidewire tip was shaped to long hook with greater than 90 degree angle in order to negotiate it through the stenosis without prolapsing into the graft or distal limb of LAD (Figure 1C). After predilation with Maverick 2.0 × 12 mm balloon, a Taxus 2.5 × 24 mm stent was deployed at 12 atmospheres with excellent angiographic results (Figure 1D). As pilot-150 guidewire was withdrawn to take the final angiographic picture, the wire would not disengage (Figure 1E). The looped wire was noted to be stuck at the distal end of the stent. A Voyager over the wire 1.5 × 12 mm balloon was attempted to pull the wire out but the attempt was not successful. Attempts to remove the guidewire using a 5F multipurpose diagnostic catheter were unsuccessful. Next a Pilot-50 wire was advanced parallel to the index wire to balloon the stented segment and remove the entangled wire, but the attempt failed. The blood flow meanwhile across the stent was TIMI-1. The patient was taken to the operating room for removal of the guide wire. During the surgery, an incision was made over the LAD and the wire loop was found to be hooked on to the stent strut. The wire was manually released and removed. The stent was extracted, artery wall repaired and two vein grafts placed onto mid and distal LAD segments.
DISCUSSIONS:There have been a number of reports on complications occurring during PCI, but we have not encountered guidewire entrapment in the distal end of a deployed stent, which made it impossible to remove the guidewire. The factors that may have contributed to formation of wire loop in this case were probably reshaping of the tip of the wire to greater than 90 degree to cross the lesion, the hydrophilic tip of the guide wire, and guidewire advancement during stent positioning against an occluded artery. The wire loop then got entrapped onto the stent struts and was difficult to retrieve. The hydrophilic properties of the wire should have helped unravel the loop but the stiffness of the wire tip did not allow this to happen.
CONCLUSION:This report describes a previously unreported complication of complex interventional procedure requiring stiff and hydrophilic wires.
DISCLOSURE:Darpan Bansal, No Financial Disclosure Information; No Product/Research Disclosure Information