Multivessel PCI procedure complicated with fracture of the wire Marcin D ę binski, MD Head: Pawel E. Buszman, MD, FACC University Hospital of Silesia, Katowice, Poland

Clinical data  Male, 77 years old  Unstable angina- CCS IV  Arterial hypertension  COPD  Paroxysmal atrial fibrillation  ECHO: LVEF=45%, general mild hypokinesis, evidence of pulmonary hypertension  Transcranial UDP Doppler: flow velocity reduction in posterior cerebral region RCA: medial 50% stenosis distal 80% stenosis LCA: –LM: no stenosis –LAD: critical 95% stenosis located in LAD / D1 bifurcation, 80-90% long lesion in distal LAD, 99% focal lesion in apical segment of LAD. –Cx: diffuse disease with % lesions in distal segment –OM: 80-90% stenosis –Long, massive calcifications in LM / LAD

Surgeon opinion (CABG) High risk CABG:  Age (>70 years)  Respiratory insufficiency (COPD)  Cerebral perfusion impairment  Mildly reduced LVEF  Diffuse disease in distal segments of coronary arteries Intended strategy Patient disqualified from CABG Treatment: multivessel staged PCI procedure: Cx / OM, LAD / D1, RCA

LCA: coronary angiography before PCI RAO / CAULAO / CRA Guiding catheter: EBU 6F Launcher

1st stage: PCI Cx/OM Predilatation and stenting of Cx with Pixel 2.5x28 mm (14atm) Predilatation and stenting of OM with Mac 2.5x22 mm (18atm)

2nd stage: PCI LAD / D1 Two BMW wires (Universal 0,014”) in LAD and D1. Predilatation of D1 ostium with Viva 2.0x15 baloon (8atm). Direct stenting with Chopin 3.0x15 mm to LAD (18 atm). POBA in distal LAD LAD : TIMI3, no dissection, no residual stenosis. The D1 wire got jammed between the stent struts and vessel wall

Fracture of the wire during removal from D1 Repeated wireing of LAD and D1 with new wires (2x Pilot 50). POBA ostium of D1 with Viva baloon 2.0x20mm During wire removal from D1 fracture of the wire occurs (junction between The distal part and the wire core)

Removal of broken wire Inflation of 3.0x40mm baloon (8atm) inside the guiding catheter. Removal of broken wire, inflated baloon and guiding catheter as a whole unit.

LCA: Final result LAO / CRA - Patient was discharged after 2 days - 3rd stage: PCI RCA was made in 2 weeks, without any complications Removed guiding catheter and wires Final angio

Take home message  Avoid high pressure inflations during stenting of main vessel when wire is in side branch (especially in calclified vessels)  Choose and check the wire carefully in above situation  Hydrophilic wire is probably the best choice  High inflation pressure beacause of incomplete stent expansion  LAD calclifications  Probable malfunction of BMW Universal wire 0,014``(weak element connection, rough surface between component connection)