Removal of an entrapped guidewire by excimer laser coronary angioplasty in patients with chronic total occlusion intervention

Abstract

Guidewire entrapment (GE) is a rare complication that warrants complex interventions or surgical procedures. Here, we report the removal of an entrapped guidewire using excimer laser coronary angioplasty (ELCA) in a case of chronic total occlusion (CTO). Plaque tissue trapped with the guidewire was also removed. Histopathological examination revealed that although specific components were entrapped with the guidewire, loosening the adjacent collagen fibres during ELCA contributed to the successful removal of the guidewire. This case showed that ELCA may be a novel modality for the removal of an entrapped guidewire in cases of CTO.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-024-04440-7.

Introduction

The prevalence of guidewire entrapment (GE) during percutaneous coronary intervention (PCI) is 0.1–0.2%, and prolonged manipulation of retrieval devices or the retention of guidewires in the coronary artery increases the risk of coronary thrombosis [1, 2]. Recent studies revealed that the prevalence of GE ranges from 0.2 to 0.5% in patients undergoing a PCI for chronic total occlusion (CTO) [3, 4]. Multiple methods have been described to extract a guide wire [4]. In the past few decades, ELCA has emerged as a useful procedure to treat uncrossable or undilatable lesions, such as chronic total occlusion (CTO), severe calcified lesions and in-stent restenosis [5]. A previous case report revealed that ELCA was effective for the retrieval of a guidewire entrapped between a deployed coronary stent and a severely calcified vessel wall [6]. Here, we report the removal of a guidewire entrapped by plaque tissue using ELCA in a patient who underwent a PCI for CTO. The tissue entrapping the guidewire was also removed and analysed via histopathology.

Case report

An 81-year-old man was admitted due to a 3-month history of exertional angina. He underwent coronary artery bypass grafting 21 years ago, and coronary computed tomography angiography revealed > 90% stenosis in the ostium of the saphenous vein graft (SVG), which bridged the left anterior descending artery (LAD). The patient had a history of previous myocardial infarction, hypercholesterolemia, diabetes, atrial fibrillation and cerebral infarction. Coronary angiography revealed chronic total occlusion (CTO) of the proximal segment of the RCA and the middle segment of the LAD (Fig. 1A). The middle segment of the first diagonal branch (D1) and the distal segment of the left circumflex (LCX) had > 90% diffuse stenosis. The ostial segment of the SVG and the proximal segment of the LAD had > 90% stenosis (Fig. 1B).

Fig. 1.

Angiographic and histopathological findings in the patient. (A) Right anterior oblique (RAO) + caudal view showing chronic total occlusion of the proximal left descending artery (LAD) (red arrow) and > 90% stenosis of the distal left circumflex (LCX) (black arrow). (B) Right anterior oblique (LAO) view showing > 90% stenosis in the ostial to proximal segments of the SVG, which bridged the LAD (red arrow). (C) RAO + cranial view indicating that guidewire was entrapped in the plaque, and the polymer sleeve and spring coils in the radiopaque region were damaged (arrow). (D, E) Excimer laser coronary angioplasty (ELCA) was utilized to ablate the plaque. The arrowhead indicated the site of ELCA catheter ablating the plaque proximal to the entrapped region in D and reaching the entrapped region in E. The arrow indicated site of the damaged polymer sleeve and spring coils in the radiopaque region (RAO + cranial view). (F) Fluoroscopy revealed that the entrapped guidewire was successfully removed from the vessel, which passed through the brachial artery and was pulled out with attached tissue. The arrow indicated the damaged polymer sleeve and spring coils, and the arrowhead indicated the ELCA catheter. (G) General image of the removed guidewire and entrapped plaque tissue. (H) Macropathological findings of the removed guidewire and the entrapped plaque tissue. The red arrowhead indicated the removed plaque. The red arrow indicated the damaged polymer sleeve and spring coils, and the black arrow indicated the bare core wire. (I) Haematoxylin–eosin staining revealed masses of fibrous tissue in the plaque. (J) Von Kossa staining revealed a hole, which was created by the guidewire, surrounded by brown calcific deposition (asterisk). (K) Masson staining distinguished smooth muscle cell (white arrowhead) and collagen fibre (black arrowhead) tissue

Although stenting of the SVG may achieve higher primary success rate than stenting of the LAD, the durability of the stenting process may not be. As such, a primary attempt of PCI of the LAD CTO was made rather than stenting the SVG. We used a Fielder XT-A guidewire, an EBU 3.75 guiding catheter, and a Finecross microcatheter. Although there was some resistance when advancing the guidewire during the drilling procedure, it crossed the occluded vessel and reached the distal true lumen. We planned to replace the CTO guidewire with a workhorse wire, but the microcatheters (Finecross and Corsair) could not pass through the occluded vessel. We tried to dilate the lesion with small diameter balloons and failed again. We found that the XT-A guidewire could not move forwards or backwards, which indicated that it was entrapped in the plaque. Fluoroscopy revealed that the polymer sleeve and spring coils were damaged (Fig. 1C). To remove the guidewire, we tried traditional techniques, such as providing microcatheter support, using parallel guidewires, dilating a balloon and deeply inserting the guiding catheter, but all attempts failed. Finally, ELCA using a 0.9 mm catheter (energy/frequency: 80 mJ/mm²/70 Hz) was used to ablate the plaque entrapping the guidewire (Fig. 1D and E). The ELCA catheter was unable to pass through the plaque and ablated the proximal part of the plaque. After 30 attempts at ablation, the guidewire was loosened and removed with the plaque tissues from the guiding catheter (Fig. 1F-H). Macro pathological examination revealed that the core wire was intact, but the polymer sleeve and spring coils were damaged (Fig. 1H) and anchored in the plaque. Although the patient was stable without other complications, we decided to terminate the procedure considering the patient’s advanced age, and a large quantity of contrast media was used. Although we recommended an elective PCI, the patient refused further revascularization and accepted medical therapy. Besides, considering that patient with advanced age and no complications of PCI, surgical intervention for revascularization was also avoided. Medication treatment including antiplatelet agent, statin, β blocker, antidiabetic agent and nitrate drugs was used after discharge. At the 1-year follow-up, the patient reported that he had not experienced any adverse cardiovascular events.

The removed plaque tissue was fixed in formalin, dehydrated and embedded in paraffin using an automatic tissue processor (ASP300S, Leica). Haematoxylin–eosin (HE), Masson and Von Kossa staining were performed to distinguish different components of plaque tissue. Histopathological examination revealed that the plaque consisted of some calcified tissue, a hole, which was made by the guidewire, a large quantity of collagen fibres and smooth muscle cells surrounding the calcified tissue (Fig. 1I-K).

This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Fuwai Hospital. The patient provided written informed consent.

Discussion

GE is a rare but severe complication of a PCI. Previous case studies revealed that retained guide wire fragments in the coronary artery may cause various complications, including thrombosis, dissection, vessel occlusion, embolization and even perforation [7–10]. The most common causes of GE or guidewire fracture are aggressive pulling of the entrapped guidewire, guidewire overrotation, guidewire deformation, atherectomy over a kinked guidewire, and guidewire jailing during stenting [3]. Severe vessel calcification and tortuosity are also associated with a higher risk of GE or guidewire fracture, which is likely attributed to equipment deformation during advancement [3]. Thus, operators should be cautious of device entrapment when dealing with such lesions.

When GE occurs during a PCI, operators should be aware of wire elongation when attempting to extract an entrapped guidewire. This manoeuvre often exacerbates the problem, making extraction more difficult. There are several interventional strategies for the management of GE, such as forceful pulling, guidewire twirling, advancement of a microcatheter/balloon/guide extension over the entrapped guidewire, balloon inflation with parallel guidewire and snaring when the guidewire is fractured [3, 11]. In addition, entering another guidewire in sub-intimal space with knuckle technique with inflating a small balloon in this space may be feasible according to previous study [12]. In rare cases, surgery was considered [13]. The most commonly used technique is the advancement of a microcatheter over the guidewire as close as possible to the site of entrapment and pulling back forcefully on the wire. However, this method may result in wire breakage. In the present case, we attempted all of these methods, except the snaring technique, as the guidewire was not fractured, and the balloon inflation technique, as parallel guidewires were unable to cross the lesion.

An analysis of the PROGRESS CTO online database (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) revealed that the retrieval of entrapped or fractured guidewires was attempted in 71.4% of the cases, and the success rate was only 26.7% [3]. If the fractured guidewire fragment is located within the coronary tree, leaving the remaining wire in place or covering it with stents may be a viable option that does not result in adverse outcomes [3, 4, 14, 15]. When the intact guidewire is unable to be removed or the fractured guidewire fragment protrudes into the aorta, surgical extraction should be considered. However, a surgical strategy is associated with a high risk of mortality [3]. Our case showed that ELCA was effective for removing entrapped guidewires. ELCA has been proven to be a safe and effective atherectomy strategy in a contemporary PCI [5]. Thus, ELCA may be a preferred option for treating GE, which could prevent the need for a surgical procedure when a traditional interventional strategy fails.

The possible risks of ELCA include laser catheter entrapment, damage to the polymer jacket of the guidewire, vessel dissection, and perforation. Although fluoroscopic view indicated that the polymer sleeve of the guidewire was damaged by rotating and pulling forces before ELCA, we could not exclude that laser energy also melted the polymer, and one should be cautious when using this technique with polymer sleeve guidewires. To validate the effect of laser ablation and reduce the probability of complications, we tried to draw the wire back every 10 rounds of laser treatment. No complications occurred in this case, which indicated that it may be a safe strategy for the retrieval of an entrapped guidewire. However, extraction of adherent plaque tissue from the vessel wall indicated the possibility of vessel damage. The energy and frequency as well as the duration of ELCA use were important for treatment. Therefore, the standard method of ELCA needed more data to establish. Compared with ELCA, the usual methods, including parallel wire technique and the use of microcatheters or balloons, had more evidence and more specific procedures to deal with GE [3, 16]. Insertion of a balloon catheter or a microcatheter over the entrapped wire allow more centering of the force on the wire which was more useful in entrapped side branch wires during bifurcation stenting. Balloon dilation along the entrapped or parallel wire enabled to loosen the plaque tissue around the entrapped guidewire. These traditional methods were more accessible and safer with less complication, which should be prioritised in case of GE. However, the microcatheter and balloon as well as parallel wire failed to pass through the entrapped site after many attempts. Thus, we try to use ELCA. In addition, we recommend pulling back the wire every few rounds of laser treatment and monitoring vital signs and ECG in the process of ELCA, which were more able to avoid complication.

Furthermore, histological findings in our study provide some clues for cause of GE. On one hand, operating factors of GE including excessive and unidirectional rotation of the guidewire during PCI may result in its head being destroyed and embedded in the plaque tissues. One the other hand, the histological examination showed that the dense fibrotic tissue and severe calcified lesion contributed to guidewire compression and damage. While a previous study revealed that heavily calcified lesions may be one cause of GE [17], the present case showed that the plaque tissue causing GE was composed of much more collagen and muscle fiber but less calcified tissue. The hard and calcified lesion lead to the deformation of guidewire and damage of polymer sleeve and spring coils. The dense fibrotic tissue made guidewire difficult to retract once it the has entered. It was difficult to judge which single tissue type resulted in GE. The specific mechanism behind needs further investigation. Although the guidewire was entrapped in the calcified region, we believe that loosening the adjacent collagen fibre during ELCA contributed to the successful removal of the guidewire considering that the collagen tissue was also removed.

Although this case reported the successful removal of entrapped guidewire in CTO lesion by ELCA, more cases should be collected in the future study which validated its efficacy and established a standard process for this method. Particularly, the comparative study for ELCA vs. other method was needed in further investigation. Moreover, long term follow-up is warranted to verify the safety of ELCA.

Conclusion

The findings of this case study suggest that ELCA may be an applicable option for the management of GE. This technique has the potential to avoid surgical intervention when traditional interventional modalities have failed.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Hanjun Zhao and Jiannan Li wrote the main manuscript text; Shaodong Ye prepared Fig. 1; Chaoxiang Liu and Yijin Wang revised the manuscript. All authors reviewed the manuscript.

Funding

This study was supported by the CAMS Innovation Fund for Medical Sciences (No: 2023-I2M-C&T-B-069).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics statement

This study was approved by the ethics committee of the Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, China.

Consent to Publish

Written informed consent was obtained from the patient for publication of this case report.

Clinical trial number

Not applicable.

Competing interests

The authors declare no competing interests.