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CASE20200109_001
| CORONARY - Complications | |
| Non-Surgical Retrieval of Fractured Wire in the Femoral Artery During Percutaneous Coronary Intervention Access in Chronic Total Occlusion Patient: How to Avoid and How to Manage | |
| Putu Primeriana Nugiaswari1, I Made Junior Rina Artha | |
| Udayana University, Indonesia1, | |
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[Clinical Information]
- Patient initials or identifier number:
PRM, Female, 74 years old
-Relevant clinical history and physical exam:
She had history of progressive angina since the last six months. History of hypertension in the last 10 years and dyslipidemia known in the last 2 years. History of hospitalized due to unstable angina was recorded in this hospital. Due to the severity of the angina, she cannot do moderate to heavy activities. Daily activities were taking a bath, walking less than 30 minutes per day, taking stairs occasionally, and eating without helps. Physical examination showed controlled hypertension 120/80mmHg, heart rate 67 beats per minute; vesicular lung sound. General condition was within normal limits. No murmur at the time of examination. Normal abdominal and extremities during examination. Physical examination during pre-catheterization showed normal radial site of puncture confirmed by the Allen test. For femoral puncture, no signs of hematoma, aneurysm, and trauma. Both left and right femoral artery had no bruit. Distal movements and arterial supply to the peripheral extremities were good. So, we conclude the patient with:
Diagnosis
 -Relevant test results prior to catheterization:
Electrocardiography showed inferior ischemia. Echocardiography showed decreased LVEF 50% with inferior wall motion hypokinetic.
 미디어1.mp4 미디어2.mp4- Relevant catheterization findings:
Coronary angiography showed normal left main, non-significant lesion at left anterior descending artery and left circumflex artery, chronic total occlusion at proximal right coronary artery. Patient was planned for double puncture approach for chronic total occlusion. After puncture in the right femoral artery, the procedure continued by left femoral artery puncture. It was difficult to release it from the introducer, and part of the wire fractured and left behind inside the lateral circumflex branch of femoral artery.
미디어3.mp4 미디어4.mp4 |
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[Interventional Management]
- Procedural step:
First attempt was snaring with Multi snare 15 mm and 3 wire Asahi Sion blue but failed and leads to the fractured wire went deeper into the branches of the left femoral artery. Second attempt was twisting with 3 wire Sion Blue, twisted several times. Fractured mini wire was only able to be pulled into the left femoral artery and became loose into distal left femoral artery. Lastly, inserted Multi snare 15 mm and fractured wire successfully snared and pulled out. No complications during procedure and patient was stable afterwards.Twisting methods used twice but failed. Then, snaring method using Multi snare 15mm can let the wire out. No complications during procedure and patient was stable afterwards.Factors affecting fractured wire varies during procedure. In this case, uncommon use of left femoral artery leads to low-femoral puncture. It induced the unfamiliar movements while drag the wire out after the puncture. Also, high possibility of wire insertion into small branch of femoral artery. Fortunately, this case can be resolved non surgically. Combination of twisting and snaring leads to successful wire retrieval.Fractured wire during percutaneous coronary intervention is a serious complication. It is usually treated surgically. Of course, it adds more complications after surgery. The main thing is how to avoid them. And for minimizing the complications, several methods need to be used in order to avoid surgical retrieval of fractured wire.
미디어5.mp4 미디어6.mp4 미디어7.mp4- Case Summary:
Factors affecting fractured wire varies during procedure. In this case, uncommon use of left femoral artery leads to low-femoral puncture. It induced the unfamiliar movements while drag the wire out after the puncture. Also, high possibility of wire insertion into small branch of femoral artery. Only a few cases have been reported. The cause for fracture can be multifactorial. Important steps towards prevention of fracture include ruling out manufacturing flaws before its use, avoiding excessive manipulation and limiting reuse as much as possible. Manufacturing flaws can be external or internal. External manufacturing flaws can be ruled out by visible inspection before inserting. Internal manufacturing flaws cannot be ruled out without sending the catheter to a quality compromise checking laboratory. We should be extra cautious while using a wire and introducer device. Percutaneous retrieval is an appealing, least invasive and safe method, provided the operator is experienced. Whenever revascularization is required, it must be done in the same setting as there may be microdissections during repeated attempts of retrieval.Fortunately, this case can be resolved non surgically. Combination of twisting and snaring leads to successful wire retrieval.Location of puncture is very important in order to avoid complications. The use of non-surgical methods such as twisting and snaring are very important to minimize surgery.
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