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A Forgotten Guidewire Causing Intracardiac Multiple Thrombi With Paradoxical and Pulmonary Embolism
Canadian Journal of Cardiology
-
(2013) 1.e1e1.e2 www.onlinecjc.ca
Images in Cardiology
A Forgotten Guidewire Causing Intracardiac Multiple Thrombi With Paradoxical and Pulmonary Embolism Okan Gulel, MD,a Korhan Soylu, MD,a Serkan Yuksel, MD,a Hasan Tahsin Keceligil, MD,b and Murat Akcay, MDa a b
Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
Department of Cardiovascular Surgery, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
A woman aged 70 years was transferred from another medical centre to our hospital because of shortness of breath, hemoptysis, and ischemic changes in the right foot (Fig. 1A). She had chronic renal failure and had been enrolled in a hemodialysis treatment program for 6 years. Transesophageal echocardiography showed a guidewire in the right atrium and right ventricle, with multiple mobile thrombi attached to it. The guidewire entered the right atrium through the superior vena cava, passed into the right ventricle through the lateral tricuspid valve annulus, and then looped in the right ventricle. One of the thrombi was entrapped within a patent foramen ovale and ; oscillated between right and left atria (Fig. 1B; Video 1 view video online). Pulmonary computed tomography angiography showed emboli in the segmental artery of the right lower lobe and a subsegmental artery of the left lower lobe. Because of the precarious state of the patient and the risk of further emboli, it was decided to take the patient for emergency cardiac surgery. The intracardiac guidewire and multiple thrombi were removed successfully (Fig. 1C). Unfortunately, because of multiple comorbidities, hemodynamic instability, and profound acidosis, she died on the second postoperative day. Vascular interventional procedures are widely used, resulting in increased complication rates. Guidewire loss may lead to thrombosis, embolism, sepsis, arrhythmia, or perforation.1 Loss of a complete guidewire is a rarely reported complication.2 Percutaneous retrieval is the preferred treatment, with low complication and high success rates.3 Various devices and techniques, such as loop snares, 2-wire or triplewire technique, basket retrievers, special catheters, grasping
forceps, or bioptomes, can be used for this purpose.1,3-5 If percutaneous retrieval fails, surgical removal should be performed. In our case, the patient underwent emergent surgical intervention because of massive thrombosis associated with the remotely embolized and unretrieved guidewire. Our case demonstrates the hazards of failure to recognize or promptly respond to an inadvertently misplaced intracardiac guidewire.
Received for publication November 18, 2012. Accepted December 10, 2012.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2012.12.010.
Corresponding author: Dr Okan Gulel, Associate Professor of Cardiology, Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey. E-mail: [email protected] See page XXX for disclosure information.
Disclosures The authors have no conflicts of interest to disclose. References 1. Savage C, Ozkan OS, Walser EM, Wang D, Zwischenberger JB. Percutaneous retrieval of chronic intravascular foreign bodies. Cardiovasc Intervent Radiol 2003;26:440-2. 2. Perez-Díez D, Salgado-Fernández J, Vázquez-González N, et al. Images in cardiovascular medicine: percutaneous retrieval of a lost guidewire that caused cardiac tamponade. Circulation 2007;115:e629-31. 3. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509-13. 4. Iturbe JM, Abdel-Karim AR, Papayannis A, et al. Frequency, treatment, and consequences of device loss and entrapment in contemporary percutaneous coronary interventions. J Invasive Cardiol 2012;24: 215-21. 5. Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol 2007;19:E230-4.
0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2012.12.010
1.e2
Canadian Journal of Cardiology Volume - 2013
Figure 1. (A) Ischemic changes in the toes of the right foot. (B) Transesophageal echocardiographic view of the guidewire in the chambers of the right side of the heart, with multiple thrombi attached to the guidewire. One of the thrombi was entrapped in a patent foramen ovale. Asterisk indicates guidewire. LA, left atrium; RA, right atrium; IAS, interatrial septum; T, thrombus. (C) Appearance of the guidewire during cardiac operation.
-
(2013) 1.e1e1.e2 www.onlinecjc.ca
Images in Cardiology
A Forgotten Guidewire Causing Intracardiac Multiple Thrombi With Paradoxical and Pulmonary Embolism Okan Gulel, MD,a Korhan Soylu, MD,a Serkan Yuksel, MD,a Hasan Tahsin Keceligil, MD,b and Murat Akcay, MDa a b
Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
Department of Cardiovascular Surgery, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
A woman aged 70 years was transferred from another medical centre to our hospital because of shortness of breath, hemoptysis, and ischemic changes in the right foot (Fig. 1A). She had chronic renal failure and had been enrolled in a hemodialysis treatment program for 6 years. Transesophageal echocardiography showed a guidewire in the right atrium and right ventricle, with multiple mobile thrombi attached to it. The guidewire entered the right atrium through the superior vena cava, passed into the right ventricle through the lateral tricuspid valve annulus, and then looped in the right ventricle. One of the thrombi was entrapped within a patent foramen ovale and ; oscillated between right and left atria (Fig. 1B; Video 1 view video online). Pulmonary computed tomography angiography showed emboli in the segmental artery of the right lower lobe and a subsegmental artery of the left lower lobe. Because of the precarious state of the patient and the risk of further emboli, it was decided to take the patient for emergency cardiac surgery. The intracardiac guidewire and multiple thrombi were removed successfully (Fig. 1C). Unfortunately, because of multiple comorbidities, hemodynamic instability, and profound acidosis, she died on the second postoperative day. Vascular interventional procedures are widely used, resulting in increased complication rates. Guidewire loss may lead to thrombosis, embolism, sepsis, arrhythmia, or perforation.1 Loss of a complete guidewire is a rarely reported complication.2 Percutaneous retrieval is the preferred treatment, with low complication and high success rates.3 Various devices and techniques, such as loop snares, 2-wire or triplewire technique, basket retrievers, special catheters, grasping
forceps, or bioptomes, can be used for this purpose.1,3-5 If percutaneous retrieval fails, surgical removal should be performed. In our case, the patient underwent emergent surgical intervention because of massive thrombosis associated with the remotely embolized and unretrieved guidewire. Our case demonstrates the hazards of failure to recognize or promptly respond to an inadvertently misplaced intracardiac guidewire.
Received for publication November 18, 2012. Accepted December 10, 2012.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2012.12.010.
Corresponding author: Dr Okan Gulel, Associate Professor of Cardiology, Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey. E-mail: [email protected] See page XXX for disclosure information.
Disclosures The authors have no conflicts of interest to disclose. References 1. Savage C, Ozkan OS, Walser EM, Wang D, Zwischenberger JB. Percutaneous retrieval of chronic intravascular foreign bodies. Cardiovasc Intervent Radiol 2003;26:440-2. 2. Perez-Díez D, Salgado-Fernández J, Vázquez-González N, et al. Images in cardiovascular medicine: percutaneous retrieval of a lost guidewire that caused cardiac tamponade. Circulation 2007;115:e629-31. 3. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509-13. 4. Iturbe JM, Abdel-Karim AR, Papayannis A, et al. Frequency, treatment, and consequences of device loss and entrapment in contemporary percutaneous coronary interventions. J Invasive Cardiol 2012;24: 215-21. 5. Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol 2007;19:E230-4.
0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2012.12.010
1.e2
Canadian Journal of Cardiology Volume - 2013
Figure 1. (A) Ischemic changes in the toes of the right foot. (B) Transesophageal echocardiographic view of the guidewire in the chambers of the right side of the heart, with multiple thrombi attached to the guidewire. One of the thrombi was entrapped in a patent foramen ovale. Asterisk indicates guidewire. LA, left atrium; RA, right atrium; IAS, interatrial septum; T, thrombus. (C) Appearance of the guidewire during cardiac operation.