Successful Percutaneous Retrieval of a Guiding Catheter Tip that Had Unexpectedly Become Detached Using a Two-Wire Technique

Abstract

Device dislodgement during percutaneous coronary intervention (PCI) is a rare but potentially life-threatening complication. We herein report the successful retrieval of a guiding catheter tip that had unexpectedly become detached in the right coronary artery during PCI in a 68-year-old man. Interventional cardiologists must be familiar with a safer and more reliable retrieval technique.

When performing percutaneous coronary intervention (PCI), PCI-related device dislodgement is a rare but potentially serious complication, which can result in systemic embolization or even death. Therefore, interventional cardiologists must be familiar with nonsurgical retrieval methods, including the small-balloon technique, two-wire technique, and the use of retrieval devices.¹ There are some reports of PCI-related device dislodgement and successful percutaneous retrieval (e.g., a guidewire fragment,² intravenous ultrasound [IVUS] catheter,³ and coronary stent⁴).

We herein describe an uncommon case in which the tip of a guiding catheter (GC) was detached by a stent balloon dilated with high pressure, which was partially inside the GC. Eventually, the detached tip was retrieved without any serious complications involving the right coronary artery (RCA) using a two-wire technique with a goose neck snare.

Case Report

A 68-year-old man with a previous myocardial infarction in the distal left circumflex and silent angina who had undergone PCI several times was admitted due to follow-up coronary angiography. Diagnostic coronary angiography performed via his right radial artery revealed a 90% de novo lesion in the diagonal branch (Dx) and a 90% stenotic lesion in the RCA ostium (Fig. 1A). We decided to perform ad hoc PCI at both sites using a 6-Fr GC (Axess KS, Asahi Intecc, Nagoya, Japan) because the GC could be used during PCI for the left and right coronary arteries. A 0.014-inch floppy guidewire (Runthrough NS Floppy, Terumo, Tokyo, Japan) was easily advanced to the Dx. After the target lesion was predilated using a 2.75-mm noncompliant balloon (NC TREK, Abbott Vascular, Tokyo, Japan) because of severe stenosis and moderate calcification that was observed on IVUS (Volcano Revolution, Volcano Co., Osaka, Japan), a 2.75 × 12 mm everolimus-eluting stent (EES; Xience Alpine, Abbott Vascular) was deployed. The final angiographic result was satisfactory after we visualized the adherent stent implantation. The PCI for the RCA ostium was completed. Similar to the procedure for the Dx, another 3.0 × 12 mm EES was deployed and partially left in the aorta using 15 atmospheric pressure in the RCA ostium following the IVUS examination and predilation (Fig. 1B). The stent balloon was then pulled back, partially in the presence of the GC, and we performed postdilation for the RCA ostium with 25 atmospheric pressure. We then observed something radiopaque during the balloon inflation (Fig. 1C, white arrow), which migrated and became attached to the mid-RCA when the balloon deflated (Figs. 1D and 2A). It was subsequently identified as the tip of the GC based on IVUS (Fig. 1D[i]). There was a small space between the coronary artery and the detached tip (Fig. 1D[ii]), probably because the tip was coaxially stuck along the RCA. Therefore, we decided to retrieve the detached tip using a two-wire technique. We used another 6-Fr GC (Launcher JR4, Medtronic, Tokyo, Japan) because we could not control the initial GC. After one guidewire (Runthrough NS Floppy) was passed inside the tip, we tried to cross another guidewire (SION black, Asahi Intecc, Nagoya, Japan) into the small space under IVUS guidance (Fig. 2B). We succeeded in passing the guidewire (Fig. 2C). The wires were entrapped by a microsnare (Amplatz GooseNeck snare, COVIDIEN, Plymouth, MN) (Figs. 1E and 2D, E) and, finally, the detached tip was retrieved from the RCA with the entire system (GC and guidewires) as a unit without any complications (Figs. 1F, 2F, and 3). Final angiography showed a good coronary flow. The patient was discharged the next day.

Fig. 1.

Percutaneous coronary intervention (PCI) of the right coronary artery (RCA) ostium. (A) Diagnostic coronary angiography (left anterior oblique cranial view) showed a 90% stenotic lesion in the RCA ostium. (B) Stent deployment (Xience Alpine, 3.0 × 12 mm). (C) Postdilatation of the RCA ostium with a balloon catheter partially inside the GC and something radiopaque was observed (white arrow). (D) The radiopaque tip migrated to the mid-RCA and IVUS identified it as the tip of the GC. (E) A guidewire was passed inside the tip and another crossed outside the tip under intracoronary ultrasound guidance. (F) Two guidewires entrapped by a goose neck snare, and then the detached tip and the PCI system being pulled back into the insertion sheath.

Fig. 2.

Schema of the retrieval method.

Fig. 3.

Successful retrieval of the detached tip of the guiding catheter.

Discussion

This case highlights two important clinical issues. First, in rare cases the tip of a GC can detach during PCI. The treatment of ostial coronary lesions suffers from a relatively high incidence of in-stent restenosis even in the drug-eluting stent era.⁵ This is because of inadequate expansion due to severe atherosclerosis⁶ and deformation of the implanted stent by torsional stress.⁷ The dilation of a large balloon catheter with high pressure is then needed to prevent the development of in-stent restenosis. The mechanisms underlying this complication in the present case suggest that a part of the stent balloon in the presence of the GC was inflated with high pressure under unconventional conditions. First, the tip of the Axess KS GC, which is softer than that of other GCs, can become even softer due to the warmth provided by the patient's body temperature. Second, the unexpectedly high pressure when the balloon catheter was inflated occurs the detached site of the GC because a stent balloon is inflated with sagging in the GC, which is not coaxial to the ostium. Finally, the inflated balloon is not separated from the GC when flaring the proximal edge of the deployed stent. According to the results from a postmarketing survey, this is the first case in which the tip of a GC from the Axess series became detached. Such a complication has also never occurred among approximately 200 cases of aorto-ostial lesion in our hospital.

The two-wire technique combined with a goose neck snare which is used like a snare may be able to retrieve dislodged devices, which cannot be removed through the GC. Eggebrecht et al reported the superiority of a small-balloon technique among the retrieval methods when retrieving dislodged stents. This is because the strategy is easy to perform with a higher success rate.¹ However, a detached GC tip must be fixed and withdrawn securely using a snare because it cannot be retrieved through the inside of the GC, unlike a dislodged stent.⁸ Additionally, there is a risk of the tip falling off. In this case, the detached GC tip could not be entrapped with commercial snares. Therefore, two wires, which were passed inside and outside of the tip and then entrapped by a goose neck snare, were used as an improvised snare. The detached tip was successfully retrieved without any complications. We believe the superiority of this retrieval method to a small-balloon technique.⁹

The incidence of this type of problem has been decreasing due to device improvements. However, the risk of complications increases if it occurs. When a PCI-related device unfortunately becomes dislodged, interventional cardiologists must be familiar with a safer and more reliable retrieval technique and with other alternative treatment options to deal with such a serious complication.