Case study: a rare case of intracoronary guidewire fracture

Clinical presentation

• 72-year-old male
• Risk factors: diabetic, active smoker
• Presentation: diagnosis of NSTEMI
  • Coronary angiogram: significant stenosis in proximal RCA, mid LAD and mid LCx
  • PPCI of RCA with 3 DES
  • 9 Days after the first procedure, he was referred for treatment of the remaining lesions in mid LAD and LCx

Procedure

Treatment of mid LCx

• Hydrophilic hi-torque guidewire
• Non compliant balloon (2.5 x 12mm)
• DES (2.5 x 19mm)

Severe mid left circumflex stenosis

Severe mid left circumflex stenosis

Angioplasty and stent placement

Angioplasty and stent placement

Result after stent deployment

Result after stent deployment

Guidewire fracture

After stenting of the mid left circumflex artery we were unable to extract the guidewire. In order to avoid further  complications we introduced a new parallel intracoronary wire.

White arrows indicate the course of the fractured guidewire.
Aside the second guidewire has been placed into the left circumflex artery (red arrow).

White arrows indicate the course of the fractured guidewire.
Aside the second guidewire has been placed into the left circumflex artery (red arrow).

Remnant filaments of the fractured guidewire

Photographic image of uncoiled filaments (blue arrows) of the fractured guidewire protruding from the guiding catheter. We can see the new intact guidewire (green colour) surrounded by the filaments of the fractured wire.

Retrieval techniques

Different techniques (loop snare, twisting wires) were applied to remove the fractured guidewire, which all resulted futile.

Loop snare

Uncoiled filaments of the guidewire captured by the loop snare.

Uncoiled filaments of the guidewire captured by the loop snare.

Twisting wire

Twisting wire technique attempt

Treatment of mid left anterior descending artery

• Non compliant balloon (3 x 20mm)
• DES (3.5 x 24mm)

Severe mid left anterior descending stenosis

Severe mid left anterior descending stenosis

Angioplasty and stent placement

Angioplasty and stent placement

Result after stent deployment

Result after stent deployment

OCT (left anterior descending)

We performed OCT of the left anterior descending artery to assess the stenting result, showing filaments of the fractured guidewire prolapsing from the ostial left circumflex (Cx) into left main and proximal left anterior descending artery.

Guidewire remnant prolapsing into the proximal left anterior descending artery (blue arrows)

Guidewire remnant prolapsing into the proximal left anterior descending artery (blue arrows)

Isolating the wire remnant by stenting

We implanted a DES (4 x 28mm) covering distal left main (LM) and proximal left anterior descending artery, in order to exclude the uncoiled filaments of the fractured guidewire from the circulation. A control OCT was performed, which showed the wire remnants trapped by the struts of the stent against the vessel wall.

We indicated dual antiplatelet therapy plus permanent oral anticoagulation for the patient, as we suspected protrusion of remnants of the fractured wire from the ostial left main coronary artery into the aorta, and there were portions of the wire free in the circulation as a result of the futile extraction techniques.

Conclusion: Follow-up

• Our patient did well since the procedure and there have not been reported any thromboembolic events till date.