Management of Retained Intervention Guide-wire: A Literature Review

Percutaneous coronary angioplasty is increasingly employed in the treatment of patients with complex coronary artery disease. Different steerable guide wires used to open occluded vessel and facilitate balloon and stent deployment. However, the guide-wire itself is not without hazard: it may perforate or dissect the vessel, but fracture or entrapment is uncommon. Its management depends on the clinical situation of the patient, as well as the position and length of the remnant. In this review we discuss the angioplasty guide-wire fracture and entrapment risk factors, potential risks and management.


INTRODUCTION
Entrapment and fracture of coronary guide-wire is a rare complication of percutaneous coronary interventions (PCI). The incidence of these complications is approximately 0.1-0.2 % [1,2]. Entrapment or over-rotation of the distal tip of the angioplasty guide wire can lead to the wire rupture [3]. Excessive bending produces a high tensile load to the guide-wire, especially when applied to the junction point between the very flexible distal 3-cm tip and the remainder of the guide wire, may result in wire fracture [4]. Retention of hardware components in the coronary tree has been recently reported to complicate coronary angioplasty [1,5].
The management of patients with retained catheter or wire fragments within the coronary artery tree is difficult. Small fractured components can be left within a chronically occluded coronary artery without sequelae [1,6,7]. Since intravascular wire fragments are highly thrombogenic, immediate surgical removal, eventually combined with bypass grafting may be indicated if percutaneous retrieval is unsuccessful or difficult [8].
Here, we review the literature for published data in English about entrapped angioplasty wire and summarize the management options available.

METHODS
We searched the Medline (PubMed), Embase, EBSCO, ScienceDirect and Cochrane databases for published data or reports in English from 1980 to 2012 using the Medical Subject Heading terms "coronary guide-wire fracture, entrapment, unraveling, or retained guide-wire fragments." *Address correspondence to this author at the Department of Adult Cardiology, Prince Sultan Cardiac Center (PSCC), Riyadh, SA. PO Box: 27656, Zip Code 11427, Saudi Arabia; Tel/Fax: +966114778771; E-mail: aal-moghairi@pscc.med.sa

RESULTS
A literature search revealed a total of 67 patients in 48 reports with guide-wire entrapment and different management approaches which involved percutaneous and surgical retrieval of entrapped fragments and conservative therapy for some cases Table 1.
The wire entrapment was reported in the right coronary artery (RCA) in 22 cases, left anterior descending artery (LAD) in 25 cases, left circumflex artery (LCX) in 19 cases and ramus intermedius artery (RI) in 2 cases.

Prevalence of Coronary Guide Wire Fracture
Hartzler and colleagues reported angioplasty guidewire retention in 8 cases of 5,400 consecutive Percutaneous transluminal coronary angioplasty (PTCA) procedures, 4 patients with retained wire segment treated conservatively had no clinical sequel on long-term follow-up [1]. The broken or retained guide-wire is a rare complication of angioplasty procedures, with an estimated incidence of 0.1 -0.2 % [1,2].

Risk Factors for Guide Wire Fracture
The possible mechanics of the rupture of these delicate, soft wires entails several factors: the usual practice of PTCA is to advance the wire across the stenotic lesion for a distance to facilitate guidance of the balloon easily across the stenosis. The 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 torqueing and unraveling of the platinum coil and precipitates rupture [31].

Risk of Retained Guide Wire Filament
The guide-wire remnants can lead to complications, such as perforation, thrombosis, embolic phenomena and vessel occlusion [5,8,31].

Rationale of Guide Wire Fragments Extraction
Since the guide-wire is thrombogenic and its presence inside the coronary or hanging up into the aorta may carry a risk of thrombo-embolization, this makes the fragment removal is essential to minimize this risk.

General Considerations of Retrieval
The percutaneous coronary intervention is usually completed uneventfully, with satisfactory results for the operator and the patient. Complications are unusual but when they do occur the sequences are serious. The operator should understand how to deal with them. One such complication is the guide-wire entrapment and the decisionmaking depends on whether the wire is still intact or fractured, and the site and extent of entrapment. The choice of guide catheter for more effective support is a crucial step and, given the prolonged nature of retrieval procedure, meticulous attention should be paid to ensure adequate anticoagulation.
In a case of guide-wire fracture, three therapeutic options are considered: percutaneous retrieval, surgical removal, or leaving the corpus alienum in-situ. The most elegant one is the non-surgical procedure by capturing the fragment depending on the operator`s comfort and experience. However, this approach carries the risk of additional vascular trauma, coronary spasms, or new fragmentation. If the removal by catheter fails and/or local myocardial ischemia arises with or without circulatory instability, and especially when extravasation of contrast medium gives evidence of vessel laceration urgent operation is indicated. Table 2 summarizes the possible methods of extraction of the retained guide-wire fragments.

Catheter Based Retrieval
There is no device designed for fractured wire retrieval. Retrieval can be attempted using a further two or more wires passed alongside the entrapped wire, and the torque is then applied to all wires and a twisting action results in wires wrapping around the retained wire and trapping it between the wrapped portions. The twisted group is then retracted, pulling out the entrapped wire out of coronary towards the guide catheter then externalization of the catheter and the wires as one unit [7,26,27].
A deep-guide catheter wedge and balloon inflation technique is another method by which the entrapped wire can be retrieved. This is a method used if the wire is still intact and the guide is over-wedged, then the balloon is advanced and inflated at the terminal part of the guide catheter and is tightly trapping the wire and the whole system is retracted to pull out the retained wire [1,3,29,30]. Another method to free the retained wire is the use of tornus micro-catheter, in which the micro-catheter is advanced with particular rotations to the tip of the wire to allow for the release of the jailed or entrapped part [28].
The use of a snare loop to retrieve the entrapped guidewire fragment was successful in some cases, but the snare may not match the vessel diameter. The gooseneck snare was the most commonly used technique and more suitable for proximal, large size vessels.   If the wire tip could not be freed and the retained fragment is entirely inside the branch, then stenting against the vessel wall might be the option [12,18]. Percutaneous methods of retrieval are listed in Table 3.

Surgical Extraction
If percutaneous techniques fail, surgery is warranted. Immediate surgical removal, eventually combined with bypass grafting, should be done. However, the unplanned cardiac surgery is associated with significant morbidity and mortality. Several surgical approaches had been reported for the treatment of retained guide-wire fragments. Bypass surgery is performed in most of the cases. Surgical extraction includes direct coronary arteriotomy or aortotomy [2-5, 8, 29, 31-47].
Left Main (LM) coronary arteriotomy and patch repair has been used for proximal wire entrapment [48].

Medical Management
The attempt to remove retained guide-wire remnants from coronary circulation is the preferable option. Some case reports and case series suggested that in selected patients, a reasonable option might be to leave the guide-wires in-situ without attempting extraction techniques if there is a chance of success seems remote based on the anatomic and technical considerations [1]. Treatment of such patients with systemic anticoagulation and anti-platelets agent with close follow up appears more appropriate for occluded or smaller distal vessels and early surgical referral if ischemic events are encountered.

Complications of Guide Wire Retrieval
Prolonged manipulation of retrieval devices or catheters may increase the risk of thrombus or air embolization. Failure of removal of retained fragments may lead to myocardial ischemia due to coronary thrombosis or obstruction. Vessel dissections or rupture from repeated instrumentation may lead to tamponade or emergency cardiac surgery with associated high mortality.

CONCLUSION
Intervention guide-wire fracture and entrapment is a rare complication of coronary interventions. The operators should be aware of this complication and be familiar with the measures to avoid it and to appropriately manage it.

CONFLICT OF INTEREST
The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS
Declared none.