Alaa gabi, md sUPERVISOR: RAMEEZ SAYYED, MD. Successful Retrieval of Fractured Pressure Wire (FFR wire) Using A Transcatheter Balloon Alaa gabi, md sUPERVISOR: RAMEEZ SAYYED, MD.

INTRODUCTION Left Heart Catheterization (LHC) is a diagnostic and therapeutic procedure that has an uncommon, but considerable risk. The incidence of retained objects during angioplasty is reported to be 0.02% in patients undergoing PCI

CASE PRESENTATION A 62-year-old Caucasian female presented for elective left heart catheterization (LHC). LHC showed: 50-60% stenosis in the Mid-LAD 70% stenosis in the Mid and Distal RCA. Decision was made to proceed with FFR of the mid LAD.

Guide catheter was engaged and FFR wire was placed in the mid LAD. We were not able to advance the FFR wire into the distal LAD and it was felt to be stuck to the mid LAD. 2.5/20mm balloon was taken down closer to the FFR wire but was not able to pass the distal tip of the wire. The balloon was then inflated close to the mid LAD lesion. It was not successful in freeing the tip of the FFR wire.

Then manual traction was applied to the FFR wire. The wire came out but was noted to have fractured at the mid body. Proximal part of the wire was taken out. Distal part of the wire had been ripped off the main body and was in the distal part of the guide catheter.

Then a different wire was passed into the LAD and multiple attempts to wrap it around the wire were unsuccessful as well

I SHOULD HAVE GONE FOR CARDIO-IMAGING!!

The residual part of the FFR wire was still in the guide catheter. The distal tip of the wire was still lodged in the LAD.

FINALLY We advanced 3.0/30mm balloon to the tip of the guide catheter. Guide was disengaged from the left main. Balloon was inflated at 14 atmospheres to entrap the wire between the tip of the guide catheter and the balloon. The guide catheter along with the balloon were pulled back as one assembly and removed as one unit through the sheath.

Another guide catheter was engaged in the ostium of the left main. Angiogram was performed which showed the native LAD to be free of any dissection

DISCUSSION The incidence of retained objects during angioplasty is reported to be 0.1- 0.2% in patients undergoing PCI. Most of the time it is caused by engagement of the wire to a side branch with spasm in the involved artery. It is assumed that frequent systolic compression can put fatigue and strain on the wire and subsequently lead to detachment during withdrawal.

Retained coronary objects can subsequently lead to arterial thrombosis, embolization or perforation. There are, however, a few cases of retained guidewire that had a benign course over extended time follow up with only conservative management.

The first case reported was in 1980, in that case the guidewire was left in the right PDA for 18 months before surgical removal during coronary bypass surgery.

Treatment of this type of complications can vary between conservative management, transcatheter approach or surgical intervention. Management depends on the anatomical location and the characteristics of the vessel involved, proximal extent of the retained material and the clinical status of the patient.

Various transcatheter methods have been used to retrieve broken wire. Retrieval using a snare loop was first reported in 1988 when a guide wire was modified to form a snare apparatus to retrieve a broken wire from the diagonal branch of the LAD. Bioptomes have been used to retrieve wires when the proximal end was close to the coronary ostia.

Double and triple wire technique has been used as well, two to three guidewires are deployed distal to the fracture wire then rotated to entangle the fracture wire before retrieval. Tornus catheter has also been used to release entrapped guidewire in severely calcified coronary arteries. Retrieval using balloon inflation at the tip of the guide catheter, as we reported in our case, has also been used with significant success.

In cases where transcatheter approach failed to retrieve the retained object, Stent deployment against the guidewire was performed.

CONCLUSION Retained fractured wire during angioplasty is a rare complication that warrants operator awareness of its risk and management.

REFERENCES Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260–1264. Vrolix M, Vanhaecke J, Piessens J, De Geest H. An unusual case of guide wire fracture during percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1988;15:99–102. 11. Hung CL, Tsai CT, Hou CJ. Percutaneous transcatheter retrieval of retained balloon catheter in distal tortuous coronary artery: A modified double-helix approach. Catheter Cardiovasc Interv 2004;62:471–475. Doring V, Hamm C. Delayed surgical removal of a guide-wire fragment following coronary angioplasty. Thorac Cardiovasc Surg. 1990;38(1):36–7. Mikolich JR, Hanson MW. Transcatheter retrieval of intracoronary detached angioplasty guidewire segment. Cathet Cardiovasc Diagn 1988;15:44–46. Collins N, Horlick E, Dzavik V. Triple wire technique for removal of fractured angioplasty guidewire. J Invasive Cardiol. 2007 Aug;19(8):E230-4. Cho YH, Park S, Kim JS, et al. Rescuing an entrapped guidewire using a Tornus catheter. Circulation. 2007;71(8):1326–7. Karabulut A1, Daglar E, Cakmak M.Entrapment of hydrophilic coated coronary guidewire tips: which form of management is best?. Cardiol J. 2010;17(1):104-8.

THANK YOU