Entrapment of Retrograde Wire in an Intervention of Chronic Total Occlusion

- Operator : Charles Chan

Entrapment of Retrograde Wire in an Intervention of Chronic Total Occlusion

- Operator: Charles Chan, MD

Clinical Presentation and baseline angiography

A 50 year old man presented with effort chest pain. He underwent stenting for a significant stenosis at the left circumflex artery (LCX) 6 months ago. Initial coronary angiogram showed a chronic total obstruction (CTO) of the previously stented LCX (Figure 1, Figure 2). Initial attempt in recannalisation the CTO was not successful as the wire exited into the false lumen. One month later, the patient was readmitted for a second attempt.

Procedure

After engaging of a 6F XB 3.5 guiding catheter, a 0.014" Terumo Runthrough was maneuvered in the distal diagonal branch through the collaterals into the obtuse marginal branch (retrograde approach) (Figure 3). Using this wire as a marker, a Miracle 3 gm was then advanced antegradely into the CTO lesion of LCX (Figure 4). The Miracle wire was successfully passed into the distal LCX with a kissing wires technique (Figure 5, Figure 6). After then, sequential dilatations with a 2.0 mm balloon were performed (Figure 7). Subsequent injections confirmed that the wire was in fact in the true lumen (Figure 8). However, when the retrograde wire (Terumo Runthrough) was withdrawn, it was not possible to retrieve it beyond the origin of the diagonal branch (Figure 9). Therefore, dilatation of the ostium of the diagonal was done using a 1.5 mm balloon (Figure 10). Further attempts to remove the wire resulted in the breakage of the wire, of which the proximal end was left ouside the left coronary ostium (Figure 11, Figure 12). Despite of the remained wire in the coronary artery, the procedure was finished and the patient was discharged without any adverse event.

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Comments

  • naveen 2006-01-28 you could have taken an over the wire balloon on the entrapped wire and pulled the wire through the balloon.Dr naveen
  • Mehdi Shahriayri Afshar 2006-01-29 How many time is needed to continue the antiplatelet(plavix) for this manner?
  • Young-Hak Kim 2006-02-02 Optimal duration of antiplatelet combination is not known in this rare circumstance. But, considering the healing process of other coronary device including stent, 1-year combination of plavix would be enough.
  • Juneyoung Yoon 2006-02-03 Operator seemed to think that the fragment removal was not necessary. Is it true? Could it be arrhythmogenic?
  • ghaffari 2006-02-09 Crossing the collateral arteries with guidewire may result in severe coronary spasm.A similar case was reported in euro PCR 2005 complication session.I prefere to administer IC nitroglycerine before any forceful maneuvers.
  • yongfanjin 2006-04-28
  • Tudor C. Poerner, MD 2006-06-13 I think nitro is no good for this complication. You are dealing with a breakage of the distal end, so leaving it in place might have been the reasonable choice. I would be interested to read a postage in 6 months about patient's clinical follow-up.

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