Distal Snare Fishing (DSF): A New Method for Successful Wire Retrieval: Navigating Retrieval Strategies Like Fishing for the Perfect Catch

ABSTRACT

In rotablation cases where guidewire fragmentation occurs, distal snaring, guided by intravascular imaging and facilitated by guide extension, can be a safe and effective alternative to proximal snaring when standard retrieval methods fail.

1. Introduction

Fragmentation and intravascular entrapment of guidewires can be considered an inherent risk to any percutaneous coronary intervention (PCI), being more likely to occur in the context of rather complex procedures, such as calcified lesions, CTOs (chronic total occlusions) and bifurcations [1, 2]. Guidewire fragments are considered to be highly thrombogenic, potentially leading to thrombosis, accelerated restenosis, coronary or systemic embolization, and perforation [3, 4, 5, 6, 7, 8]. Rota wire transection is among the most infrequent complications described in the literature, and it might result in potentially life‐threatening consequences [9, 10]. Thus, percutaneous retrieval can be recommended in favor of a conservative approach, if feasible, and mostly if the detached fragments are situated in the proximal part of an epicardial coronary artery. The proper retrieving method remains unknown given that the literature consists only of isolated case reports with inconsistent approaches [1, 11, 12, 13, 14, 15]. This case highlights the challenges of coronary wire fracture and demonstrates how intravascular imaging, guide extension, and snaring techniques can complement each other to achieve successful retrieval.

2. Case History

A symptomatic 65‐year‐old female patient, with a medical history of hypercholesterolemia and stage 2 arterial hypertension, has been referred for PCI of the right coronary artery (RCA) (Figure 1A). A 6F Judkins Right guiding catheter was crossed through the right radial, and initial pre‐dilation with a 3.0 mm non‐compliant (NC) balloon at more than 20 atm revealed a non‐expandable lesion, which required debulking using a rotational atherectomy RA (ROTAPRO, Boston Scientific, USA). The workhorse wire was exchanged with a Floppy RotaWire (Boston Scientific, USA), and the 1.5 mm burr was tested outside of the patient, followed by successful advancement up to the catheter tip using Dynaglide mode. After several runs at 170,000 rpm, the burr successfully passed the mid calcified RCA lesion without any speed deceleration (Figure 1B).

FIGURE 1.

(A) Initial angiographic appearance of the right coronary lesions. (B) Successful burr passage during rotablation.

During the first moments of the retrieval, despite applying the same protocols (activation of the Dynaglide mode and press on the release brake button), the system alarmed the staff members through the high‐pitched drilling noise, which raised suspicions, and was showing speeds of up to 170,000 rpm, despite multiple attempts to reactivate the Dynaglide mode. In lack of other options, the operator continued the maneuver, and the burr came out together with a cut part of the floppy rota wire. At this point, the position of the distal radiopaque marker of the rota wire was unchanged inside the RCA, and the location of the fracture was uncertain.

3. Treatment

A workhorse wire is passed in the distal RCA and an OCT pass (OPTIS system, Abbott Vascular, Santa Clara, CA, USA) reveals the proximal part of the fractured wire at the ostium of the RCA (Figure 2).

FIGURE 2.

(A) OCT pullback revealing the proximal edge of the fractured rotawire located at the ostium of the right coronary artery (RCA), indicated by the orange arrow. (B) The absence of wire proximal to the ostium inside the guide catheter (right panel) confirms the proximal location of the fractured wire segment. The exact anatomical location of the OCT static image is displayed in the upper left corner of each panel. OCT, optical coherence tomography; RCA, right coronary artery.

With a deep‐seated guiding catheter, a NC 3.0/20 mm balloon was inflated at 4 atm in mid‐RCA and slowly retracted while inflated, with the expectation of withdrawing the Rota wire fragment inside the catheter. However, fluoroscopy reveals uncoiling of the wire in the ascending aorta towards the left aortic sinus (Figure 3A). Using the same guiding catheter, several unsuccessful attempts were made to snare out the wire from the ascending aorta using the En Snare 12–20 mm System (Merit Medical Systems) (Figure 3B). After failing, an intracoronary snaring with a MiniOne 4 mm snare was attempted, but the proximal part of the rota wire cut was impossible to capture. At this point, the strategy was changed to a distal wire snaring (Figure 4A–D).

FIGURE 3.

Wire uncoiled in the ascending aorta. (A) Yellow arrow indicates the location of the fractured wire extending from the right coronary ostium (blue arrow) inside the ascending aorta. (B) Aortic snaring attempts using En Snare 12–20 mm System.

FIGURE 4.

Distal wire snaring inside the right coronary artery. (A) Blue arrow indicates the location of the distal guide‐extension tip, red arrow indicates the workhorse wire on which the guide‐extension catheter is advanced, yellow arrow shows the distal fragment of the fractured rotawire. MiniOne snare loop exists the guide‐extension tip and is oriented towards the inner curvature of the vessel. (B–D) Distal wire snaring and pullback inside the guide extension.

A 6F Guideliner is advanced in the mid‐distal RCA in order to be able to advance the snare system through the calcifications of the RCA. After reaching the distality of the coronary artery, the loop was unfolded and slowly retracted in order to catch the distal tip of the wire which by hazard was orientated towards the inner curvature of the vessel, simplifying therefore the maneuver (Figure 3A).

4. Outcome and Follow‐Up

After the completion of the wire retrieval, there were no coronary flow disturbances, and the calcified segments appeared to be adequately prepared, which was confirmed by intravascular imaging. Two Xience stents (Abbott Vascular, Santa Rosa, CA, USA) were implanted from mid‐RCA until the ostium (3.0/48 mm, followed proximally by a 3.5/23 mm). Both stents were post‐dilated using a 4.0 mm NC balloon. Final OCT run revealed good expansion and apposition of the stents, proper ostial coverage, and no residual wire fragments. The postprocedural evolution was uneventful, and the patient was discharged the following day.

5. Discussion

Cases of wire transection during RA are considerably rare in the literature [9, 10, 16]. Herein, the cause was attributed to a system malfunction that did not allow the rotablation platform to adequately reduce the rotation speed despite proper steps having been employed. Intravascular imaging proved useful to properly identify the location of the fracture. If the fracture had been located inside the guiding catheter, then a simple balloon‐trapping technique might have been able to easily remove the wire from the RCA. However, given the ostial location of the transection, there were limited strategies available.

Similar to any wire coronary fracture, available strategies include conservative management, catheter‐based retrieval techniques, and surgical removal. There are some reports available that seem to advocate for conservative management, showing the absence of any adverse events in the medium term [17, 18]. This could potentially be explained by the endothelization process, which might be able to render the fragments immobile and less thrombogenic. If conservative management is opted for, there are no recommendations regarding the proper antiplatelet or anticoagulation regimens, for which the need for a prolonged duration should be anticipated given the risk of thrombus formation that could propagate proximally [19]. Nevertheless, the combination of literature reports with practical intuition creates the current inclination toward wire removal, particularly when this can be achieved through percutaneous means. There are several catheter‐based retrieval techniques, all with unpredictable success rates. The most common strategies include snaring, wire tangling, and stenting over the remnants [3]. A review published more than 10 years ago revealed that the most common technique employed was snaring of the fragments followed by balloon‐trapping inside the guiding catheter [3].

In our case, given that OCT showed the proximal edge of the wire at the ostium of the RCA, it was considered important to affix the wire using a low‐pressure inflated balloon and pull it inside the guiding catheter to facilitate an aortic snaring. There is only one case described in the literature where a similar strategy was attempted, which was equally ineffective [5]. In our case, this strategy managed to uncoil the wire towards the ascending aorta. This offered the opportunity to attempt the most common retrieval strategy of proximal snaring in a large vessel. Despite persistent efforts, it proved unsuccessful, which could partly be explained by the much softer and tensile nature of the Floppy RotaWire. A different approach, which consists of intentionally wrapping the broken wire with one or multiple coronary wires using rapid and simultaneous rotation, was not attempted in this particular case. The successful extraction of the wire was ultimately accomplished through distal snaring of the fragment. Distal snaring, while more challenging due to the difficulty of advancing the snare system to the distal part of the vessel, offers a higher success rate since it is performed in a more confined space, which increases the likelihood of catching the wire tip. The advantage here lies in the fact that the snare loop is pulled back with the tip of the wire, making retrieval more feasible. However, distal snaring also presents risks, such as potential distal fragment embolization or losing the snared fragment during pullback, especially as it approaches the guiding catheter. The technical difficulty of advancing a bulky snare system to the distal vessel must also be considered. These issues can be mitigated by using a guide extension, carefully advanced using balloon‐assisted tracking, and positioned just proximal to the distal tip of the fragment. In this situation, the loss of wire tension along the vessel wall curvature, combined with the short length and softer construct of the wire tip, facilitated the snaring of the distal part of the wire fragment.

When attempting proximal snaring, as opposed to distal, the main challenge lies in the fact that, in cases of large intraluminal space, the snare loop can easily pass the proximal extremity of the wire without catching it. In contrast, distal snaring is less prone to this issue, given the more limited space, thus increasing the chances of success.

6. Conclusion

Wire transection during rotational atherectomy, though rare, presents significant challenges. Intravascular imaging is essential for locating fractures and guiding retrieval strategies. Proximal snaring, though commonly used, can be difficult in large intraluminal spaces where the loop may miss the wire. Distal snaring, despite being more technically challenging, offers a higher success rate in confined spaces. This case demonstrates that distal snaring, supported by guide extension and balloon‐assisted tracking, can be a successful approach for wire retrieval.

Author Contributions

Silviu Dumitrascu: conceptualization, methodology, writing – original draft, writing – review and editing. Ignacio Amat Santos: supervision, validation. Elias Bentakhou: conceptualization, formal analysis, investigation, methodology, writing – review and editing. Claudiu Ungureanu: conceptualization, formal analysis, methodology, project administration, supervision, validation, writing – original draft, writing – review and editing.

Consent

Written informed consent was obtained from the patient to publish this report.

Conflicts of Interest

The authors declare no conflicts of interest.

Dumitrascu S., Santos I. A., Bentakhou E., and Ungureanu C., “Distal Snare Fishing (DSF): A New Method for Successful Wire Retrieval: Navigating Retrieval Strategies Like Fishing for the Perfect Catch,” Clinical Case Reports 13, no. 7 (2025): e70517, 10.1002/ccr3.70517.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.