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\begin{document}

\title{A life trapped by a guidewire- A rare sequence of complications after an
eletive coronary angioplasty}



\author[1]{José João Monteiro}%
\author[1]{Hélder Ribeiro}%
\author[2]{Fatima Neves}%
\author[1]{Ilídio Moreira}%
\affil[1]{Centro Hospitalar de Tras-os-montes e Alto Douro EPE}%
\affil[2]{Centro Hospitalar de Vila Nova de Gaia Espinho EPE}%


\vspace{-1em}



  
  \date{June 06, 2024}


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\selectlanguage{english}
\begin{abstract}
Though rare, guidewire loss or fracture after percutaneous coronary
intervention (PCI) can occur. Coronary perforations (CP) are rare
complications of PCI and can be classified as type I (extraluminal
crater), II (myocardial or pericardial blushing) and III (contrast
streaming or cavity spilling).%
\end{abstract}%



\sloppy


\textbf{Introduction}

Bifurcation lesions are complex lesions that remain among the most
challenging fields of treatment with percutaneous coronary intervention
(PCI). These lesions are associated with increased rates of procedural
complications, restenosis, and adverse events than lesions in the body
of the vessel (1). Following complex coronary interventions, there is a
relatively higher rate of complications, such as coronary dissection,
coronary perforation, acute coronary syndrome, and arrhythmias. (2)

Coronary perforations (CP) are rare complications of percutaneous
coronary intervention and can be classified as type I (extraluminal
crater), II (myocardial or pericardial blushing), and III (contrast
streaming or cavity spilling). Types I and II coronary perforations are
caused by stiff or hydrophilic guidewires. Type I has a benign
prognosis, whereas type II coronary perforations have the potential to
progress to tamponade. (2). The incidence of CP during PCI varies
between 0,12 and 0,82\% (3,4,5) In a large database from British
Cardiovascular Intervention Society Database, coronary perforations were
more common in women or older, with a greater burden of comorbidity
including hypertension, hypercholesterolemia, previous myocardial
infarction, peripheral vascular disease, and left ventricular
dysfunction.

Coronary guidewire fracture is another rare complication of percutaneous
coronary intervention (PCI). Guidewire fracture could be due to:
entrapment into or behind stent struts, wire cutting by rotational
atherectomy devices, stuck wire into a distal tortuous vessel and
structural failure of the wire. Management options include retrieval by
snare or wire intertwining, deployment of the stent across broken
fragments, or leave the wire alone if it is in an insignificant distal
vessel or branch. (6)

Drug-eluting stent (DES) implantation using the `provisional' approach
is the gold standard for percutaneous treatment of patients with
unselected bifurcated lesions, although some experts consider this
approach unsuitable for the treatment of more complex bifurcation
anatomies (7).

\textbf{Case Report}

A 65-year man with type II diabetes and hypertension was referred for
elective coronary angiography owing a history of exertional angina and a
CT Angiography suggestive of obstructive coronary disease (Calcium score
\textgreater{}400 Agatston). Echocardiography displayed mild septum
hypertrophy and mild degenerative valve changes without hemodynamic
significance. It did not show any segmental kinetic change and an
ejection fraction of 65\% was calculated by Simpson's method. The
systolic function of the right ventricle was preserved (TAPSE = 22) and
no pericardial effusion was present.

Coronary angiography revealed non-significant obstructive disease in the
left coronary and two critical lesions in the right coronary artery
(RCA): critical stenosis of proximal/medium right coronary and a
critical lesion at a bifurcation between distal RCA and posterolateral
artery (PLA) (figure 1).

The patient was submitted to a percutaneous coronary intervention of
bifurcation lesion through balloon inflation (3,0x15 mm) followed by
stent implantation in distal RCA (ONYX 3,5mm x 34 mm) (figure 1). PLA
was protected by a guidewire (BMW) and it was made proximal optimization
technique (POT) to warrant better stent to vessel apposition. When the
operator tried to pull out the PLA guidewire it was trapped between the
vessel wall and respective coronary stent. It fractured and its proximal
extremity was located at the radial artery. A Microsnare technique was
carried out trying to remove it, without success.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1- angiogram showing critical stenosis of proximal/medium RCA and
a critical lesion at bifurcation between distal RCA and PLA (left
profile projection).

Operator called an Heart Team discussion to decide the better strategy
to patient, either conservative or cardiothoracic surgery in order to
remove intracoronary guidewire. Considering anatomical and technical
issues that made unlikely the success of the surgical approach and after
risk-to-benefit considerations, experts decided to choose the
conservative approach. On the other hand, It was decided to implant a
coronary stent in PLA and were implanted two other coronary stents: at
the proximal extremity of the first stented lesion to correct a proximal
dissection (ONYX 3,5x34m) and at proximal RCA

(ONYX 4,0x34 mm) overinflated with high-pressure NC balloon (4x8mm).
(figure 2). This strategy sought stabilization of total guidewire
alongside RCA to promote endothelialization of the tip of trapped
guidewire in coronary vessel wall reducing the risk of in situ
thrombosis.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2 - angiogram after PCI of RCA obstructive lesions (left anterior
oblique projection).

After the procedure, the patient remained asymptomatic and
hemodynamically stable. Echocardiography did not reveal pericardial
effusion either any other change in relation to the previous exam.
Patient was discharged next day with the following medication:
acetylsalicylic acid 100mg, Clopidogrel 75 mg, bisoprolol 2,5 mg,
atorvastatin 40 mg , ramipril 5 mg, metformin 1000mg and sitagliptin 5
mg. He maintained follow-up in cardiology consultation during 3 years
without any clinical intercurrence during this period.

Three years later the patient was admitted in the emergency department
after a syncopal episode preceded by chest discomfort and diaphoresis.
At admission patient presented with chest discomfort, diaphoresis and
widespread weakness and had signs of shock as hypotension, impaired
tissue peripheral perfusion (hiperlactacidemia 5,1 mmol/L), tachycardia
(120 bpm) and tachypnea (30 cpm) . EKG showed sinus rythm, 120 bpm, with
Q waves in DIII and aVF and 1 millimeter horizontal ST-segment
depression in V4, V5 and V6 derivations. Emergence echocardiography
showed a pericardial effusion with 25 mm in posteroinferior topography
and collapse of right cardiac cavities. It was performed an emergent
pericardiocentesis with immediate drainage of 1500mL of hematic-looking
liquid.

After clinical and hemodynamic stabilization of the patient, taking into
account his clinical background and the possible iatrogenic etiology of
hemopericardium, the cardiac surgery reference center was contacted and
the patient was transferred to that department to be submitted to an
emergent exploratory sternotomy.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

After median sternotomy and pericardiotomy surgeons could observe an
externalized guidewire on the lower wall, on the way to the PLA that was
partially removed through the inferior heart wall (total extension of 17
cm) (figure 3).

A B

Figure 3- Manual extraction of guide wire after pericardiotomy (A).
Extenson of extracted guidewire (B).

Concurrently during intraoperative transesophageal ecocardiography it
was observed a hyperechogenic filamental structure along the ascending
aorta (figure 4 ).

\textbf{Hosted file}

\verb`image5.gif`  available at \url{https://authorea.com/users/563515/articles/610691-a-life-trapped-by-a-guidewire-a-rare-sequence-of-complications-after-an-eletive-coronary-angioplasty}

Figure 4- Intraoperative transesophageal ecocardiography showing a
hyperechogenic filamental structure along the ascending aorta

After remotion of the distal portion of the trapped guidewire through
pericardial space , it was decided to perform an Computed tomography
angiography that shown a foreign body (extension of 6 centimeters) in
internal right carotid artery, associated with a pseudoaneurysm at the
distal end of it (figure 5)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

A B

Figure 5- Computed tomography angiography showing a fragment of the
trapped guidewire in right coronary artery (A) and pseudoaneurysm at the
distal end of it (B)

Owing to the risk of a percutaneous intravascular approach, conditioned
by the presence of a pseudoaneurysm, it was removed through transverse
arteriotomy of the carotid artery by a vascular surgeon. The
pseudoaneurysm was removed intraoperatively and a top-to-top anastomosis
between carotid bifurcation and right internal carotid artery was
performed with Prolene 6/0 (figure 6).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}

A B

Figure 6- Arteriotomy of right internal carotid artery (A) and remotion
of fragment of trapped guidewire (B).

The patient was discharged few days later, with any other intercurrence
during hospitalization and 18 months later, patient remains
asymptomatic, with excellent functional status.

\textbf{Discussion}

Coronary perforation during or after percutaneous interventions are rare
but potentially life-threatening incidents often resulting in emergency
surgery. While iatrogenic perforations occurred in the catheterization
laboratory may be treated immediately at the site of their occurrence
with several possible techniques, namely through different kinds of
covered stents, rupture of pre-existing coronary pathology frequently is
associated with a possible delayed diagnosis, giving rise to serious
clinical events ( i.e. myocardial infarction, cardiac tamponade, malign
arrhythmias or sudden death). (8)

Though rare, guidewire loss or fracture after PCR can occur. There are
different percutaneous and surgical approaches that try to fix this
possible complication. When percutaneous techniques are not successful,
depending on patient clinical factors and the length of free wire in the
aorta, both surgery or a conservative approach, which includes the
extension of double antiplatelet therapy, are valid. (9, 10) In this
clinical case the risk-to-benefit was considered favorable to a
conservative strategy given the low probability of success of surgery
approach removing trapped guidewire. In order to prevent thrombotic
events, a stent was implanted in PLA to promote endothelization of the
trapped guidewire in the coronary vessel and long-term double
antiplatelet therapy was prescribed.

\textbf{Conclusion}

There are different percutaneous and surgical approaches that try to fix
PCI complications. The choice between surgery or a conservative approach
is decided in each case, according to tecnhical and patient features. In
this clinical case, the risk-to-benefit was considered favorable to
follow an initial conservative strategy after a guidewire fracture given
the low probability of success of surgery approach removing it.

\textbf{Figure Legends}

Figure 1- angiogram showing critical stenosis of proximal/medium RCA and
a critical lesion at bifurcation between distal RCA and PLA (left
profile projection)

Figure 2 - angiogram after PCI of RCA obstructive lesions (left anterior
oblique projection).

Figure 3- Manual extraction of guide wire after pericardiotomy (A).
Extenson of extracted guidewire (B).

Figure 4- Intraoperative transesophageal ecocardiography showing a
hyperechogenic filamental structure along the ascending aorta.

Figure 5- Computed tomography angiography showing a fragment of the
trapped guidewire in right coronary artery (A) and pseudoaneurysm at the
distal end of it (B).

Figure 6- Arteriotomy of right internal carotid artery (A) and remotion
of fragment of trapped guidewire (B).

\textbf{References}

1-Narbute, I. \emph{et al, ``} Real-life Bifurcation - Challenges and
Potential Complications\emph{''} , European Caridology Review, July 2011

2- Al-Mukhaini, \emph{et al} ,''Coronary Perforation and Covered Stents:
An Update and Review'', Heart-Views June 2011, 63--70.

3- Kinnaird, T. \emph{et al} , ``Incidence, Determinants, and Outcomes
of Coronary Perforation During Percutaneous Coronary Intervention in the
United Kingdom Between 2006 and 2013'', Circulation: Cardiovascular
Interventions. August 2016

4-Gunning MG, Williams IL, Jewitt DE, Shah AM, Wainwright RJ, Thomas
MR.Coronary artery perforation during percutaneous intervention:
incidence and outcome.\textbf{Heart} .~2002;~\emph{88} :495--498

5 - Fejka M, Dixon SR, Safian RD, O'Neill WW, Grines CL, Finta B,
Marcovitz PA, Kahn JK.Diagnosis, management, and clinical outcome of
cardiac tamponade complicating percutaneous coronary
intervention.\textbf{Am J Cardiol} .~2002;~\emph{90} :1183--1186.

6- ``Broken guidewire -- A tale of three cases'', Case reports Inidan
Heart Journal, December 2015

7-Burzotta, L, Trani, C, ``Technical Aspects of Provisional Stenting in
Percutaneous Treatment of Complex Bifurcation Lesions'', Interventional
Cardiology, September 2013

8- Elsner, M. and Zeiher,A, ``Perforation and rupture of coronary
arteries'', Springer Link, August 1998

9-~Calvert, P \emph{et al} , ``Coronary guidewire loss: distal wire
fragment fracture in the coronary circulation'' PCR online

10- Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler
NL,~\emph{et al} . Increased coronary perforation in the new device era.
Incidence, classification, management and outcome. Circulation
1994;90:2725-30

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