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CASE20191022_008
| CORONARY - Cardiac Surgery/Hybrid Revascularization | |
| Retrieval of Entrapped Guide-Wire with Rescue Off-Pump Coronary Artery Bypass Grafting | |
| Hyo-Hyun Kim1, Jung-Hwan Kim1, Hyunchel Joo2, Seung Hyun Lee1, Sak Lee1, Young-Nam Youn1, Kyung Jong Yoo1 | |
| Severance Hospital, Korea (Republic of)1, Yonsei University, Korea (Republic of)2, | |
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[Clinical Information]
- Patient initials or identifier number:
KCW
-Relevant clinical history and physical exam:
A 64-year-old man with a history of percutaneous coronary intervention at far distal left circumflex artery (LCX) 7 years ago. Multi-detector CT imaging demonstrated a subtotal occlusion of the distal LCX with 70% tubular eccentric narrowing of proximal to mid LAD.
-Relevant test results prior to catheterization:
Diagnostic angiography performed at 2014 revealed the patency atdistal LCX stent.
 2014-prior angio.mp4- Relevant catheterization findings:
Left radial arterial access was obtained with 7 French EBU sheaths. The left main coronary artery with a 7 French guide catheter. Contrast injection revealed a 30 mm long occlusion with calcification.
2019-present angio.mp4 |
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[Interventional Management]
- Procedural step:
Antegrade wire escalation with a Hi-Torque Versaturn advanced through a Runthrough (Terumo) resulted in subintimal guidewire entry. The guidewire to advance through the occlusion, and balloon inflation was performed to insert Biofreedom stent (3.0 X 33 mm) into that. In angiography, stent under–expansion was revealed. So, additional balloon inflation was performed to fully expansion. And then, the guidewire and balloon catheter could not be withdrawn, with balloon stent strut entrapped guidewire. Attempts were made to push and pull for free the entrapped guidewire, and multiple balloon inflations were performed. Multiple retrieval attempts were unsuccessful. Emergent surgery was planned to perform. Heparin infusion was maintained during transfer to operating room. Thein situ LIMA grafting was to the distal LAD. Saphenous vein graft wassequentially anastomosed to 1st and 2nd obtuse marginal branch and PD. Interestingly, proximal portion of the vein graft shrank. So, we attempted re-anastomosis, but the phenomenon persisted even though the lumen was confirmed. Finally, we anastomosed newly vein graft to previous vein graft to reliable antegrade flow. The perioperative transit time flow measurement was satisfied. After that, we tried to withdraw the catheter with manual guiding, and the guidewire was removed. Native coronary artery was intact without rupture or injury. All procedure was performed under off-pump techniques. The patient had an uneventful recovery.
postOPCAB.mp4- Case Summary:
Entrapment and fracture of coronary guide-wire is rare complicationof percutaneous coronary interventions (PCI). The incidence of these complicationsis approximately 0.1-0.2 %. Since intravascular wire fragments are highly thrombogenic, immediate surgical removal, eventually combined with bypass grafting may be indicated if percutaneous retrieval is unsuccessful or difficult.
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