Guidewire complications
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The use of coronary guidewires can be associated with perforation of the epicardial coronary artery, entrapment of the wire in the vessel, wire fracture and detachment or embolization of the wire tip. This chapter discusses the management of these complications.
Vessel Perforation
Definition and Incidence
Coronary perforations are uncommon (< 1%) complications of percutaneous coronary intervention (PCI) and are associated with significant morbidity and mortality rates. [1] [2] [3] [4] [5] Coronary perforations are infrequent in patients undergoing balloon angioplasty (0.1%) compared with patients undergoing atheroablative therapy (1.3%; P< 0.001) [6] [7] Perforation due to coronary guidewires may present late after the procedure.
The prognosis following coronary perforation depends on the extent of extravastion into the pericardium [8].
Classification
The following classification scheme has been developed based on angiographic appearance of the perforation:
- Type I perforations including an extraluminal crater without extravasation
- Type II perforations containing pericardial or myocardial blushing
- Type III perforations having a ≥ 1 mm diameter with contrast streaming; and cavity spilling [9].
Coronary Artery Perforation
Shown below is perforation of the right coronary artery during PCI: <youtube v=sFSKnzL1kp0/>
- Class I perforations were associated with no deaths and cardiac tamponade in 8% of patients.
- Class II perforations were associated with no deaths and cardiac tamponade in 13% of cases
- Class III perforations were associated with death in 19% and cardiac tamponade in 63% of patients [10].
Treatment of Vessel Perforation
Initial management strategies include:
- Prolonged balloon inflation: For this reason it is often wise for a cardiac catheterization laboratory to have perfusion balloons in a range of sizes available.
- Reversal of anticoagulation: This would included administration of protamine to reverse heparin and administration of platelets if abciximab has been administered.
- In refractory cases, polytetrafluoroethylene covered stents (stent grafts) can be used to seal the perforation [11] [12] .
Approximately one third of cases of PCI-associated coronary artery perforation require emergent cardiac surgery.
Guidewire Entrapment
Guidewire entrapment is more likely to occur in the following scenarios:
- calcified vessels ( eg RCA) at the tip.
May be prevented by avoiding using the same wire on multiple interventions or multiple crossing.
My need to advance a small profle balloon or a small caliber catheter (transit) to the “attachement” site and use traction. Caution : Perforation.
- May occur when a buddy wire gets trapped between a stent and the vessel wall. Gentle traction may bring the wire out of the stent. The coating of the tip may “deglove” and be left behind, which could be “pushed and pasted” against the vessel wall with another stent. May need surgery to retrieve it. The tip may completely detach, then the management is as above.
Fracture and Embolization of the Guidewire Tip
Care should be taken to remove the guidewire from the body very slowly so as to not result in distal embolization of the wire tip. If resistance is felt as the wire is being pulled back, further investigation should be made as to whether the wire is entrapped in a stent strut or other structure.
Management of Guidewire Tip Embolization
May have to snare it.
May be left in situ, speacially if small and unable to retrieve. Could use a stent to “push and paste” it to the vessel wall.
Surgery may be needed.
Guidewire Fracture
Guidewire fracture should be identified immediately and the wire should be replaced. Failure to identify guidewire fracture can lead to distal embolization of the fractured segment.
References
- ↑ Fasseas P, Orford JL, Panetta CJ, Bell MR, Denktas AE, Lennon RJ, Holmes DR, Berger PB. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J. 2004 Jan; 147 (1):140-5. PMID 14691432
- ↑ Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236
- ↑ Javaid A, Buch AN, Satler LF, Kent KM, Suddath WO, Lindsay J Jr, Pichard AD, Waksman R. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol. 2006 Oct 1; 98 (7):911-4. Epub 2006 Aug 7. PMID 16996872
- ↑ Klein LW. Coronary artery perforation during interventional procedures. Catheter Cardiovasc Interv. 2006 Nov; 68 (5):713-7.PMID 17039517
- ↑ Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, Montorfano M, Carlino M, Finci L, Sangiorgi G, Colombo A. Incidence, predictors, in-hospital, and late outcomes of coronary artery perforations. Am J Cardiol. 2004 Jan 15; 93 (2): 213-6. PMID 14715351
- ↑ Dippel EJ, Kereiakes DJ, Tramuta DA, Broderick TM, Shimshak TM, Roth EM, Hattemer CR, Runyon JP, Whang DD, Schneider JF, Abbottsmith CW. Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management. Catheter Cardiovasc Interv. 2001 Mar; 52 (3):279-86. PMID 11246236
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec; 90 (6): 2725-30. PMID 7994814
- ↑ Ly H, Awaida JP, Lespérance J, Bilodeau L. Angiographic and clinical outcomes of polytetrafluoroethylene-covered stent use in significant coronary perforations. Am J Cardiol. 2005 Jan 15; 95 (2): 244-6. PMID 15642559
- ↑ Gercken U, Lansky AJ, Buellesfeld L, Desai K, Badereldin M, Mueller R, Selbach G, Leon MB, Grube E. Results of the Jostent coronary stent graft implantation in various clinical settings: procedural and follow-up results. Catheter Cardiovasc Interv. 2002 Jul; 56 (3): 353-60. PMID 12112888