- Email: [email protected]
Rupture of guide wire during percutaneous transluminal coronary angioplasty
J
THORAC CARDIOVASC SURG
1989;97:467-9
Rupture of guide wire during percutaneous transluminal coronary angioplasty Mechanics and management Two rare cases of rupture of the guide wire during percutaneous transluminaJ coronary angioplasty are described. Both patients required emergency surgical retrieval of the retained fragments and myocardial revascuJarization. The possible mechanics of the event and the options in the management are discussed with a review of the literature on this rare complication of percutaneous transluminaJ coronary angioplasty.
Probal K. Ghosh, FRCSE, MCh, Gunter Alber, MD: Roland Schistek, MD, and Felix Unger, MD, Salzburg, Austria, and Traunstein, Federal Republic of Germany
Since the introduction of percutaneous transluminal coronary angioplasty (PICA) in September 1977, close to a million procedures have been performed or attempted worldwide. Rates of complications precipitating acute coronary events necessitating emergency bypass operations range from 3.7% to 7%. Fracture of the guide wire leading to emergency aorta-coronary bypass remains a rare complication. This report presents two cases of rupture of the guide wire in which the wire had to be removed surgically. Case reports CASE 1. A 51-year-old man with double-vessel disease was admitted to the hospital with stable angina. Coronary arteriography had revealed an 80% stenosis of the first obtuse marginal branch of the circumflex and 80% narrowing of the middle right coronary artery (RCA) with another similar stenosis in the distal RCA. At coronary angioplasty, a 0.12-inch steerable guide wire (Schneider-Medintag, Zurich, Switzerland) and a 2.5 mm Pass Key Schneider-Gruentzig balloon catheter were used. The proximal stenosis of the RCA was successfully dilated. To dilate the distal stenosis of the RCA, the guide wire was exchanged for a O.lG-inch steerable
From the Department of Cardiac Surgery, Landeskrankenanstalten, Salzburg, Austria, and the Department of Cardiology,' City Hospital, Traunstein, Federal Republic of Germany. Received for publication April 22, 1988. Accepted for publication Sept. 2, 1988. Address for reprints: Probal K. Ghosh, Herzchirurgie Salzburg, Landeskrankenanstalten, Miillner Hauptstrasse 48, A 5020 Salzburg, Austria.
wire. After this guide wire was advanced, it snapped during maneuver. The proximal end of the retained fragment remained within the RCA distal to the dilated proximal lesion. The procedure was discontinued and that patient was transferred for an emergency operation. Cardiopulmonary bypass and moderate systemic hypothermia were instituted for the initial exploration, which revealed no apparent abnormality. An arteriotomy near the crux did not disclose an intracoronary wire. The arteriotomy was extended proximally up to the distal stenosis, where the tip of the fragment was located just outside the arterial wall. The wire had perforated the plaque and was impacted in the wall. A 25 ern long uncoiled wire fragment was extracted. Aortacoronary bypass to the RCA and the first obtuse marginal branch was performed. The patient made a rapid, uneventful recovery. CASE 2. A 52-year-old woman with hypertension and exertional angina had had a posterior wall infarction in March 1987 and underwent tests 1 month later. A coronary arteriogram showed a 40% narrowing of the mid-RCA and a 90% stenosis of the distal RCA near the crux. PTCA of the RCA was attempted with a 300 em long O.l2-inch steerable guide wire (Schneider) and a 3.0 mm Schneider-Gruentzig balloon catheter. While the guide wire was being advanced, it entered a right atrial branch and became immobilized. Attempts at withdrawal led to uncoiling and breakage of the wire. The proximal end of the retained fragment was noticed in the ascending aorta. Attempts to remove the fragment with a pigtail catheter, a wire snare, and a Dormia basket (P. Flugbeil gmbh, Ottobrun, Federal Republic of Germany) were not successful. At emergency operation, after cardiopulmonary bypass was initiated, the RCA was inspected. No indications of any perforation or laceration were seen, but minor ecchymosis was observed near the mid-RCA. The wire could not be found through an arteriotomy at the anticipated site. There was no
467
The Journal of Thoracic and Cardiovascular Surgery
4 6 8 Ghosh et al.
Table I. Surgical retrieval: Review of the literature Site ofPTCA
Site of impaction
Associated findings
Year
Reference
1985 1985
2
RCA LAD
Not mentioned Diagonal branch
1986
3
LAD
Epicardial fat
1986 1987
4
LAD Septal branch
1987 1987 1988
6 7
LAD Distal anastomosis of vein graft to RCA LAD LAD RCA RCA
Not mentioned Ruptured diagonal branch. hemopericardium, cardiac tamponade Perforation, laceration of LAD; dissection of posterior intima Intracoronary soft thrombus No additional damage
LAD Perforating branch RCA plaque Atrial branch
No additional damage No additional damage Perforation Ecchymosis
1
5
Present report
LAD, Left anterior descending artery.
intracoronary thrombus. A small ascending arteriotomy revealed the proximal end of the wire, which was gently withdrawn. A 37 cm long uncoiled fragment was extracted. Aorta-coronary bypass to the RCA was performed. The patient had an uneventful recovery and was discharged 10 days later. Discussion
Surgical retrieval of broken PTCA guide wire fragments has been reported in seven rare instances in the literature (Table I). All patients underwent emergency aorta-coronary bypass. Only one death occurred, which was ascribed by the authors to a 3o-minute delay because no operating room was available. 2 The guide wire most commonly used was the USCI Very Flexible J 0.014-inch wire (USCI Div. of C. R. Bard, Billerica, Mass.). The possible mechanics of the rupture of these delicate, soft wires entails several factors. The usual practice at PTCA is to advance the wire across the stenotic lesion for a distance to facilitate guidance of the balloon easily across the stenosis. The J guide wire is rotated during advancement to negotiate the correct course. This rotational maneuver should never exceed 180 degrees. Excessive rotation, especially if the tip is not free, leads to lateral stress caused by torquing and unraveling of the platinum coil and precipitates rupture. In addition, if the wire enters a small branch (such as the acute marginal, atrial, ventricular, diagonal, or septal branch) of an index artery (the RCA, left anterior descending, or circumflex artery) the wire may get trapped. Once the distal tip becomes wedged, the withdrawal pull on the wire may lead to uncoiling of the platinum segment, stretching, and consequent weakening. Further pulling may rupture the wire. ArceGonzalez and colleagues' noted in their surgical patient that wire entrapment contributed to the detachment of
the forming ribbon from the distal tip weld and to unraveling of the platinum coil. In an in vitro test, they demonstrated that direct traction on the guide wire without prior rotation breaks the wire; however, this break occurs at the proximal solder joint.' If a manufacturing defect of the wire were a potentiating cause, the likely location of rupture would be at this proximal solder joint. Entrapment of the wire may also occur at a plaque in the index artery itself. Entry into a totally obstructed native artery or bypass graft also potentiates entrapment. An additional potential cause of breakage may be the technical error of inadvertent forceful use, which may cause bending or fracture. If the guiding catheter is inadvertently displaced from the coronary ostium, then during the attempt to withdraw an immobilized wire the wire may become severed between the edge of the guiding catheter and the coronary ostium. Additional contributing factors are vessel tortuosity, distal lesions, eccentric lesions, and total or partial loss of the ability to steer the guide wires. The main diagnostic feature of rupture is the appearance of an area of radiotranslucency in the spring coil during the maneuver. This sign should alert the operator to the unraveling of the coil and rupture. There are three potential dangers of retained guide-wire fragments: coronary occlusion, systemic thromboembolism, and embolization of the fragment. Thrombotic occlusion of the coronary artery segment in which the fragment is lodged may lead to myocardial infarction and hemodynamic instability. Keltai, Bartek, and Bir04 observed that it took less than 5 minutes for an intracoronary thrombus to develop in their patient, and despite an uneventful emergency operation and recovery and patent grafts, the patient had a perioperative myocardial
Volume 97 Number 3 March 1989
infarction. The risk of thromboembolism is increased if the proximal end of the broken guide-wire fragment lies in the ascending aorta. Platelet and fibrin deposits may lead to cerebral and systemic embolization. Embolization of the wire fragment has been reported by Hartzler, Rutherford, and McConahay in two of their patients: from the proximal circumflex to a large obtuse marginal branch and from the RCA to the abdominal arota. However the risk of fragment embolization may be less likely when the fragment is immobilized and relatively fixed in the coronary artery system. The possible options in the management of broken guide-wire fragments are nonsurgical removal, leaving them in situ, and surgical retrieval. Successful nonsurgical removal of fragments entrapped in coronary circulation has been reported in nine patients. Implements used include a Dotter retrieval catheter, pigtail ventriculography catheter, wire snare, Amplatz guiding catheter, Caves-Schultz bioptome, and en bloc withdrawal of the whole system (guide wire, balloon catheter, and guiding catheter). A monorail catheter is reported to be useful, because it does not need an exchange wire. Intracoronary nitroglycerin may relieve the spasm of an entrapping small side branch and free the immobilized tip. However, insertion of a Dotter catheter at times causes further fragmentation of the retained guide wire segment. Wire snares may cause damage to the wall of the aorta. En bloc withdrawal is not always successful. Moreover, the potential hazards of arterial injury, dissection, and spasm are inherent in all extraction maneuvers. Though conventional wisdom warrants removal of retained fragments, three reports exist in the literature in which fragments were left in situ in eight patients." In a follow-up from 6 to 60 months, Hartzler, Rutherford, and Mcf'onahay" observed no adverse clinical sequelae attributable to wire debris. They postulated that the wire segment would become covered with an outgrowth of vascular endothelium that would render the segments immobile and nonthrombogenic. Small retained metallic components located in the distal coronary circulation in the absence of coronary occlusion may be benign. Short metallic segments, in their opinion, can be left without adverse sequelae, particularly if they are contained within a chronically occluded coronary segment. Surgical retrieval and aorta-coronary bypass are
Guide wire rupture during PTCA
469
indicated in the presence of hemodynamic instability, myocardial ischemia, suspicion of coronary perforation, and laceration or dissection, and when the proximal end of the fragment lies in the aorta as noticed in these reported surgically treated cases. Wire fracture usually occurs before dilatation of the significant coronary stenosis that was the original indication for PTCA. Moreover nonsurgical removal may not be possible in many instances and has its own hazards. We believethat prompt operation helps resolve the emergency satisfactorily. Therefore, access to emergency surgical backup remains an integral part of organization for PTCA. REFERENCES 1. Palenkar J, Schiessler A, Hempel B, John A, Bticherl ES. Emergency coronary surgery following unsuccessful angioplasty: postoperative results as a function of preoperative status. In: Unger F, ed. Coronary artery surgery in the Nineties. Berlin: Springer-Verlag, 1987: 79-81. 2. Gonzalez-Santos JM, Vallejo JL, Pineda T, Zuazo JA. Emergency surgery after coronary artery disruption complicating PTCA: report of four cases. Thorac Cardiovasc Surg 1985;33:244-7. 3. Khonsari S, Livermore J, Mahrer P, Magnusson P. Fracture and dislodgement of floppy guidewire during percutaneous transluminal coronary angioplasty. Am J Cardiol 1986;58:855-6. 4. Keltai M, Bartek I, Biro V. Guidewire snap causing left main coronary occlusion during coronary angioplasty. Cathet Cardiovasc Diagn 1986;12:324-6. 5. Arce-Gonzalez JM, Schwartz L, Ganassin L, Henderson M, Alridge H. Complications associated with the guide wire in percutaneous transluminal coronary angioplasty. J Am Coil Cardiol 1987;10:218-21. 6. Stellin G, Ramondo A, Bortolotti U. Guidewire fracture: an unusual complication of percutaneous transluminal coronary angioplasty. Int J Cardiol 1987;17:339-42. 7. Lotan C, Hasin Y, Stone D, Meyers S, Appelbaum A, Gotsman MS. Guide wire entrapment: a potentially dangerous complication. Cathet Cardiovasc Diagn 1987;13:309-12. 8. Hartzler GO, Rutherford BD, McConahay DR. Retianed percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260-4. 9. Steele PM, Holmes DR, Mankin HT, Schaff HV. Intravascular retrieval of broken guide wire from the ascending aorta after percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1985;11:623-8.
THORAC CARDIOVASC SURG
1989;97:467-9
Rupture of guide wire during percutaneous transluminal coronary angioplasty Mechanics and management Two rare cases of rupture of the guide wire during percutaneous transluminaJ coronary angioplasty are described. Both patients required emergency surgical retrieval of the retained fragments and myocardial revascuJarization. The possible mechanics of the event and the options in the management are discussed with a review of the literature on this rare complication of percutaneous transluminaJ coronary angioplasty.
Probal K. Ghosh, FRCSE, MCh, Gunter Alber, MD: Roland Schistek, MD, and Felix Unger, MD, Salzburg, Austria, and Traunstein, Federal Republic of Germany
Since the introduction of percutaneous transluminal coronary angioplasty (PICA) in September 1977, close to a million procedures have been performed or attempted worldwide. Rates of complications precipitating acute coronary events necessitating emergency bypass operations range from 3.7% to 7%. Fracture of the guide wire leading to emergency aorta-coronary bypass remains a rare complication. This report presents two cases of rupture of the guide wire in which the wire had to be removed surgically. Case reports CASE 1. A 51-year-old man with double-vessel disease was admitted to the hospital with stable angina. Coronary arteriography had revealed an 80% stenosis of the first obtuse marginal branch of the circumflex and 80% narrowing of the middle right coronary artery (RCA) with another similar stenosis in the distal RCA. At coronary angioplasty, a 0.12-inch steerable guide wire (Schneider-Medintag, Zurich, Switzerland) and a 2.5 mm Pass Key Schneider-Gruentzig balloon catheter were used. The proximal stenosis of the RCA was successfully dilated. To dilate the distal stenosis of the RCA, the guide wire was exchanged for a O.lG-inch steerable
From the Department of Cardiac Surgery, Landeskrankenanstalten, Salzburg, Austria, and the Department of Cardiology,' City Hospital, Traunstein, Federal Republic of Germany. Received for publication April 22, 1988. Accepted for publication Sept. 2, 1988. Address for reprints: Probal K. Ghosh, Herzchirurgie Salzburg, Landeskrankenanstalten, Miillner Hauptstrasse 48, A 5020 Salzburg, Austria.
wire. After this guide wire was advanced, it snapped during maneuver. The proximal end of the retained fragment remained within the RCA distal to the dilated proximal lesion. The procedure was discontinued and that patient was transferred for an emergency operation. Cardiopulmonary bypass and moderate systemic hypothermia were instituted for the initial exploration, which revealed no apparent abnormality. An arteriotomy near the crux did not disclose an intracoronary wire. The arteriotomy was extended proximally up to the distal stenosis, where the tip of the fragment was located just outside the arterial wall. The wire had perforated the plaque and was impacted in the wall. A 25 ern long uncoiled wire fragment was extracted. Aortacoronary bypass to the RCA and the first obtuse marginal branch was performed. The patient made a rapid, uneventful recovery. CASE 2. A 52-year-old woman with hypertension and exertional angina had had a posterior wall infarction in March 1987 and underwent tests 1 month later. A coronary arteriogram showed a 40% narrowing of the mid-RCA and a 90% stenosis of the distal RCA near the crux. PTCA of the RCA was attempted with a 300 em long O.l2-inch steerable guide wire (Schneider) and a 3.0 mm Schneider-Gruentzig balloon catheter. While the guide wire was being advanced, it entered a right atrial branch and became immobilized. Attempts at withdrawal led to uncoiling and breakage of the wire. The proximal end of the retained fragment was noticed in the ascending aorta. Attempts to remove the fragment with a pigtail catheter, a wire snare, and a Dormia basket (P. Flugbeil gmbh, Ottobrun, Federal Republic of Germany) were not successful. At emergency operation, after cardiopulmonary bypass was initiated, the RCA was inspected. No indications of any perforation or laceration were seen, but minor ecchymosis was observed near the mid-RCA. The wire could not be found through an arteriotomy at the anticipated site. There was no
467
The Journal of Thoracic and Cardiovascular Surgery
4 6 8 Ghosh et al.
Table I. Surgical retrieval: Review of the literature Site ofPTCA
Site of impaction
Associated findings
Year
Reference
1985 1985
2
RCA LAD
Not mentioned Diagonal branch
1986
3
LAD
Epicardial fat
1986 1987
4
LAD Septal branch
1987 1987 1988
6 7
LAD Distal anastomosis of vein graft to RCA LAD LAD RCA RCA
Not mentioned Ruptured diagonal branch. hemopericardium, cardiac tamponade Perforation, laceration of LAD; dissection of posterior intima Intracoronary soft thrombus No additional damage
LAD Perforating branch RCA plaque Atrial branch
No additional damage No additional damage Perforation Ecchymosis
1
5
Present report
LAD, Left anterior descending artery.
intracoronary thrombus. A small ascending arteriotomy revealed the proximal end of the wire, which was gently withdrawn. A 37 cm long uncoiled fragment was extracted. Aorta-coronary bypass to the RCA was performed. The patient had an uneventful recovery and was discharged 10 days later. Discussion
Surgical retrieval of broken PTCA guide wire fragments has been reported in seven rare instances in the literature (Table I). All patients underwent emergency aorta-coronary bypass. Only one death occurred, which was ascribed by the authors to a 3o-minute delay because no operating room was available. 2 The guide wire most commonly used was the USCI Very Flexible J 0.014-inch wire (USCI Div. of C. R. Bard, Billerica, Mass.). The possible mechanics of the rupture of these delicate, soft wires entails several factors. The usual practice at PTCA is to advance the wire across the stenotic lesion for a distance to facilitate guidance of the balloon easily across the stenosis. The J guide wire is rotated during advancement to negotiate the correct course. This rotational maneuver should never exceed 180 degrees. Excessive rotation, especially if the tip is not free, leads to lateral stress caused by torquing and unraveling of the platinum coil and precipitates rupture. In addition, if the wire enters a small branch (such as the acute marginal, atrial, ventricular, diagonal, or septal branch) of an index artery (the RCA, left anterior descending, or circumflex artery) the wire may get trapped. Once the distal tip becomes wedged, the withdrawal pull on the wire may lead to uncoiling of the platinum segment, stretching, and consequent weakening. Further pulling may rupture the wire. ArceGonzalez and colleagues' noted in their surgical patient that wire entrapment contributed to the detachment of
the forming ribbon from the distal tip weld and to unraveling of the platinum coil. In an in vitro test, they demonstrated that direct traction on the guide wire without prior rotation breaks the wire; however, this break occurs at the proximal solder joint.' If a manufacturing defect of the wire were a potentiating cause, the likely location of rupture would be at this proximal solder joint. Entrapment of the wire may also occur at a plaque in the index artery itself. Entry into a totally obstructed native artery or bypass graft also potentiates entrapment. An additional potential cause of breakage may be the technical error of inadvertent forceful use, which may cause bending or fracture. If the guiding catheter is inadvertently displaced from the coronary ostium, then during the attempt to withdraw an immobilized wire the wire may become severed between the edge of the guiding catheter and the coronary ostium. Additional contributing factors are vessel tortuosity, distal lesions, eccentric lesions, and total or partial loss of the ability to steer the guide wires. The main diagnostic feature of rupture is the appearance of an area of radiotranslucency in the spring coil during the maneuver. This sign should alert the operator to the unraveling of the coil and rupture. There are three potential dangers of retained guide-wire fragments: coronary occlusion, systemic thromboembolism, and embolization of the fragment. Thrombotic occlusion of the coronary artery segment in which the fragment is lodged may lead to myocardial infarction and hemodynamic instability. Keltai, Bartek, and Bir04 observed that it took less than 5 minutes for an intracoronary thrombus to develop in their patient, and despite an uneventful emergency operation and recovery and patent grafts, the patient had a perioperative myocardial
Volume 97 Number 3 March 1989
infarction. The risk of thromboembolism is increased if the proximal end of the broken guide-wire fragment lies in the ascending aorta. Platelet and fibrin deposits may lead to cerebral and systemic embolization. Embolization of the wire fragment has been reported by Hartzler, Rutherford, and McConahay in two of their patients: from the proximal circumflex to a large obtuse marginal branch and from the RCA to the abdominal arota. However the risk of fragment embolization may be less likely when the fragment is immobilized and relatively fixed in the coronary artery system. The possible options in the management of broken guide-wire fragments are nonsurgical removal, leaving them in situ, and surgical retrieval. Successful nonsurgical removal of fragments entrapped in coronary circulation has been reported in nine patients. Implements used include a Dotter retrieval catheter, pigtail ventriculography catheter, wire snare, Amplatz guiding catheter, Caves-Schultz bioptome, and en bloc withdrawal of the whole system (guide wire, balloon catheter, and guiding catheter). A monorail catheter is reported to be useful, because it does not need an exchange wire. Intracoronary nitroglycerin may relieve the spasm of an entrapping small side branch and free the immobilized tip. However, insertion of a Dotter catheter at times causes further fragmentation of the retained guide wire segment. Wire snares may cause damage to the wall of the aorta. En bloc withdrawal is not always successful. Moreover, the potential hazards of arterial injury, dissection, and spasm are inherent in all extraction maneuvers. Though conventional wisdom warrants removal of retained fragments, three reports exist in the literature in which fragments were left in situ in eight patients." In a follow-up from 6 to 60 months, Hartzler, Rutherford, and Mcf'onahay" observed no adverse clinical sequelae attributable to wire debris. They postulated that the wire segment would become covered with an outgrowth of vascular endothelium that would render the segments immobile and nonthrombogenic. Small retained metallic components located in the distal coronary circulation in the absence of coronary occlusion may be benign. Short metallic segments, in their opinion, can be left without adverse sequelae, particularly if they are contained within a chronically occluded coronary segment. Surgical retrieval and aorta-coronary bypass are
Guide wire rupture during PTCA
469
indicated in the presence of hemodynamic instability, myocardial ischemia, suspicion of coronary perforation, and laceration or dissection, and when the proximal end of the fragment lies in the aorta as noticed in these reported surgically treated cases. Wire fracture usually occurs before dilatation of the significant coronary stenosis that was the original indication for PTCA. Moreover nonsurgical removal may not be possible in many instances and has its own hazards. We believethat prompt operation helps resolve the emergency satisfactorily. Therefore, access to emergency surgical backup remains an integral part of organization for PTCA. REFERENCES 1. Palenkar J, Schiessler A, Hempel B, John A, Bticherl ES. Emergency coronary surgery following unsuccessful angioplasty: postoperative results as a function of preoperative status. In: Unger F, ed. Coronary artery surgery in the Nineties. Berlin: Springer-Verlag, 1987: 79-81. 2. Gonzalez-Santos JM, Vallejo JL, Pineda T, Zuazo JA. Emergency surgery after coronary artery disruption complicating PTCA: report of four cases. Thorac Cardiovasc Surg 1985;33:244-7. 3. Khonsari S, Livermore J, Mahrer P, Magnusson P. Fracture and dislodgement of floppy guidewire during percutaneous transluminal coronary angioplasty. Am J Cardiol 1986;58:855-6. 4. Keltai M, Bartek I, Biro V. Guidewire snap causing left main coronary occlusion during coronary angioplasty. Cathet Cardiovasc Diagn 1986;12:324-6. 5. Arce-Gonzalez JM, Schwartz L, Ganassin L, Henderson M, Alridge H. Complications associated with the guide wire in percutaneous transluminal coronary angioplasty. J Am Coil Cardiol 1987;10:218-21. 6. Stellin G, Ramondo A, Bortolotti U. Guidewire fracture: an unusual complication of percutaneous transluminal coronary angioplasty. Int J Cardiol 1987;17:339-42. 7. Lotan C, Hasin Y, Stone D, Meyers S, Appelbaum A, Gotsman MS. Guide wire entrapment: a potentially dangerous complication. Cathet Cardiovasc Diagn 1987;13:309-12. 8. Hartzler GO, Rutherford BD, McConahay DR. Retianed percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260-4. 9. Steele PM, Holmes DR, Mankin HT, Schaff HV. Intravascular retrieval of broken guide wire from the ascending aorta after percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1985;11:623-8.