Surgical retrieval of entrapped coronary angioplasty guidewire from the aorta

Introduction

Entrapment or retention of coronary angioplasty hardware such as a guidewire is a rare but serious complications of coronary interventions. Percutaneous methods of retrieval are often successful. ¹ However, in half of the reported patients in whom interventions were performed, surgery was required. ² Device entrapment like this can lead to serious complications including myocardial ischemia, infarction, or lethal arrhythmia due to intracoronary thrombosis. ³ These patients usually undergo an emergency surgical bypass procedure. We describe a case of this rare complication in which the entrapped guidewire was retrieved successfully from the left anterior descending artery (LAD) and the aorta through an aortotomy following anastomosis of the left internal mammary artery to the LAD.

Case report

A 35-year-old gentleman with no relevant medical history presented with unstable angina. He showed no evidence of myocardial infarction, but he had a positive stress test. Follow-up cardiac catheterization showed a long 90% stenotic lesion of the proximal LAD; the other vessels were free of disease. Percutaneous transluminal coronary angioplasty was attempted but it failed. At the end of the procedure, the LAD guidewire (BMW Galileo 0.014 guidewire, 180 cm in length) was trapped in the LAD (Figure 1), and attempts to free and retrieve the guidewire using an Amplatz gooseneck catheter failed. The patient was taken to the operating room. Transesophageal echocardiography showed the entrapped guidewire in the aortic root, arch, and descending aorta (Figure 2). After a median sternotomy and pericardiotomy, an off-pump anastomosis of the left internal mammary artery to the LAD was carried out following heparinization. Cardiopulmonary bypass was instituted at normothermia through aorto-atrial cannulation, and aortic root cardioplegic arrest was achieved after crossclamping the aorta. The left internal mammary artery graft was clamped during the brief period of cardioplegic arrest. A transverse aortotomy was performed and the guidewire was seen in the aortic root, entering the left coronary ostium (Figure 3). The short length of the guidewire was first removed distally from the proximal LAD, followed by proximally from the full length of the aorta (Figure 4) by gently pulling using blunt forceps. The aorta was declamped after deairing, and the patient was weaned off cardiopulmonary bypass. Decannulation was undertaken after protamine reversal, and routine closure was performed. Transesophageal echocardiography confirmed successful retrieval of the guidewire. The patient had an uneventful recovery and was discharged from the hospital on the 6th postoperative day.

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Figure 1.

Coronary angiogram showing the guidewire entrapped in the left anterior descending artery.

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Figure 2.

Transesophageal echocardiography showing the entrapped guidewire (arrows) in the descending aorta: transverse and longitudinal sections.

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Figure 3.

Intraoperative photograph showing the guidewire being removed from the aortic root.

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Figure 4.

Photograph showing the two ends of the guidewire after removal: distal (thin arrow) below and proximal (thick arrow) above.

Discussion

Retained hardware within the coronary circulatory system presents a unique set of problems. The reported incidence of entrapment or fragmentation of such devices during or after percutaneous transluminal coronary angioplasty ranges from 0.2% to 0.8%. ⁴

The presence of a fractured segment of an angioplasty balloon catheter or guidewire in a coronary artery carries the risk of grave complications such as acute embolization leading to acute coronary thrombosis and myocardial infarction. Such hardware retained intraluminally within a coronary vessel serves as a nidus for endothelial injury and platelet deposition, putting the vessel at risk of acute thrombosis. ⁵ The presence of a calcified proximal lesion is believed to prevent withdrawal of the broken catheter. In such cases, surgical removal is usually required. ⁶ Extremely angulated segments may reduce the success rate of coronary stenting and contribute to the stent entrapment. ⁷ Overzealous, inappropriate, or unnecessary use of novel or high-profile devices may also lead to complications. When a wire or catheter is trapped, vigorous efforts at percutaneous removal are sometimes attempted before a cardiac surgeon is contacted. These attempts create further risk to the endothelium of an already diseased vessel. Therefore, when possible, we advocate removal of the wire or catheter and downstream grafting of the coronary artery, unless it can be ascertained that the vessel is otherwise unharmed.

An algorithm proposed by Texas Heart Institute can serve as an important guideline for managing these patients. ⁸ Identifying the full extent of a fractured guidewire can be difficult fluoroscopically but is particularly important if the wire extrudes into the ostium and the aorta, as was the situation in our case. Surgical intervention should be accompanied by transesophageal echocardiography to evaluate the distal extent of the wire or catheter. This method is useful for locating the end of the wire in the aortic root and the proximal aorta. ⁸ If the retained wire or catheter cannot be removed easily, it should be trimmed as high as possible within the coronary ostium to prevent future thrombus formation and possible systemic embolization. Alternatively, the wire can be retrieved distally through an arteriotomy; however, this approach is not always straightforward due to the presence of atherosclerotic disease or stents, and because of the prospect of further injury to the vessel. In the event of failed interventional retrieval and persistent signs of ischemia, the patient should be urgently referred for surgery. The success of surgery in this circumstance is determined primarily by the clinical status of the patient before the operation. For patients in cardiogenic shock, the risk of death remains 20% to 50%. Additional risk factors depend upon the duration, extent, and location of ischemia.

In the current era with increasing numbers of percutaneous interventions, the incidence of entrapped or retained hardware within the coronary system is going to rise. As a result, interventional cardiologists and cardiac surgeons around the world are going to encounter more of these complications; both should be familiar with the various percutaneous retrieval techniques of baskets, bioptomes, intertwined guidewires for catheter removal, and optimal surgical management in cases of unsuccessful nonsurgical retrieval. ⁷