although advances in percutaneous coronary intervention ( pci ) have dramatically improved the outcomes of ischemic heart disease , procedure - related complications such as device fractures or dislodgements are also increased .
guidewire fractures are very rare with an incidence of approximately from 0.1% to 0.2% of cases.1)2 ) although remnant guidewires can lead to life - threatening complications,3)4 ) and recently , percutaneous retrieval techniques are considered good therapeutic options , there have been several reports on the remnants being left in coronary artery and aorta without any serious adverse outcomes.5)6 ) we describe the case of fatal subacute stent thrombosis caused by guidewire fractures with retained remnant eleven days after the index procedure .
a 72-year - old woman was referred from another hospital for coronary intervention of distal left main disease .
the electrocardiogram ( ecg ) showed normal sinus rhythm without any changes in abnormal st segment .
her left coronary angiogram ( cag ) showed tight luminal narrowing at the distal left main coronary artery ( lm ) with preserved distal coronary flows { thrombolysis in myocardial infarction ( timi ) grade 3 } ( fig .
the left coronary artery was engaged with the extra back up ( ebu ) 3.5 guiding catheter ( 6 fr , medtronic , minneapolis , mn , usa ) with side hole via right radial artery .
two 0.014 inch guidewires were positioned into the left anterior descending artery ( lad ) ( balanced middle weight , abbott vascular , santa clara , ca , usa ) and the left circumflex artery ( lcx ) ( runthrough , terumo , tokyo , japan ) .
predilatation and balloon kissing were done with 2.520 mm balloon ( trek , abbott vascular , santa clara , ca , usa ) in lad up to 12 atm and 2.020 mm balloon ( genoss , suwon , korea ) in lcx up to 10 atm .
we implanted a 2.7518 mm everolimus - eluting stent ( xience prime , abbott vascular , santa clara , ca , usa ) at the proximal segment of lcx with minimal protrusion into the lm , and which was crushed using 2.520 mm trek balloon .
we also deployed a 3.018 mm everolimus - eluting stent ( xience prime , abbott vascular , santa clara , ca , usa ) from the lm trunk to the proximal segment of lad across the ostium of lcx .
we were about to insert intravascular ultrasound ( ivus ) catheter into the lcx after successful re - wiring into the lcx with runthrough guidewire , and then , we realized that the guidewire was kinked at small branch of lcx ( fig .
even though the wire was broken at the junction of hard shaft and soft wire tip , we could see the elongated and uncoiled wire remnant swinging in the ascending aorta on cine view ( fig .
we changed guiding catheter for a bigger one ( 7 fr , ebu ) via right femoral approach .
several attempts for removal of remnant wire by using amplanz gooseneck snare ( 6 fr , 15 mm , loop snare catheter , ev3 , plymounth , mn , usa ) was not successful ( fig .
we tried again by using endoscopic biopsy forceps ( 6 fr , 1550 mm , olympus , tokyo , japan ) ( fig .
eventually , we caught the broken wire and could remove a part of the wire ( fig .
3 ) , leaving the soft tip in the small branch ( fig . 4a and b ) .
the radiopaque remnant was fixed to the vessel wall by an additional stent implantation ( 2.7523 mm , xience prime , abbott vascular , santa clara , ca , usa ) .
elongated and un - coiled filaments were not seen within lm and proximal lcx on cine view .
however , the uncoiled filaments were identified within the distal lm and proximal lcx on ivus ( fig .
after seven days , the patient was discharged with triple antiplatelet agents including aspirin , clopidogrel , and cilostazol .
four days later , the patient revisited the emergency department with acute chest pain in shock state .
ecg showed st - segment elevation in lead avr and avl and st - segment depression in lead ii , iii , avf , and v 4 - 6 . shortly afterwards
percutaneous cardiopulmonary support ( pcps ) was applied at the bed side right away , and then , the patient was sent to the coronary catheterization laboratory .
bed side echocardiography demonstrated severe lv systolic dysfunction with about 20% of the ejection fraction .
emergency cag was performed immediately and it revealed that lm was totally occluded due to subacute stent thrombosis ( fig . 5 ) .
the timi flow was recovered to grade ii after aspiration thrombectomy and balloon angioplasty at lm ( 3.020 mm , ruyjin , terumo , tokyo , japan ) and lcx ( 2.520 mm , trek ) .
after recovery of coronary flow , the patient 's heart function seemed to improve echocardiography gradually . on the 6th hospital day , weaning from pcps was successfully , however , the patient was in septic condition , with decreasing courses due to unknown bacterial or fungal infections . disseminated intravascular coagulation was getting worse and acute renal failure was not improving despite the continuous renal replacement therapy . eventually , we lost the patient on the 15th hospital day .
with the continued advances in percutaneous techniques for revascularization of coronary artery diseases , interventional cardiologist began to intervene in more complex coronary lesions .
entrapments on hardware materials of angioplasty have been reported for guidewires , balloons , rotablator systems , stents , and angiographic catheters usages.7)8 ) the complications of remnant guidewires could be life - threatening because it could lead to coronary thrombosis , perforation and embolization.3)4 ) bifurcation lesions , tortuous and calcified lesion , use of firm tipped guidewire are important risk factors for guidewire entrapments and fractures . especially when the hydropilic coated guidewire tips can be easily broken in calcified and tortuous lesions .
therefore , the operator should more careful , when treating complex lesions with hydrophilic guidewires.9 ) there are several methods recommended for the treatment of fractured guidewire remnants . some cardiologists with limited interventional experiences preferred urgent surgery .
however , the surgery should be considered after failures of interventional methods , and there are no guidelines for surgical indications.9 ) percutaneous retrieval techniques of fractured guidewires include the use of snare loop or goose - neck snare , double or triple wire rotation,10 ) use of tornus catheter,11 ) use of a balloon as a wedge for extracting guidewire fragments12 ) and biopsy forceps.13 ) these techniques may be difficult and time - consuming for inexperienced cardiologists , and furthermore , they can cause endothelial injury , dissection and thrombosis.14 ) the best way to solve the sticky problem is the complete removal without complications .
however , when it is not possible to get rid of the wires , fixing the thrombogenic materials to the vessel wall with stents can be a viable alternative to minimize the risk of thrombosis by device remant.9 ) remained guidewires in the coronary arteries may not always cause serious adverse effects .
non - metallic and hydrophilic guidewire tips are not highly thrombogenic , and it is reasonable to leave such remnants in small side branches or chronically occluded vessels.9 ) several conservative treatment cases were reported . in the reported cases ,
leaving the guidewire remnants within the left coronary artery and ascending aorta did not cause any serious complications during several months of follow - up period.5)6 ) conservative treatments are preferred when risks of interventional techniques or surgery outweigh its benefits in particular to patients who remain asymptomatic and hemodynamically stable.6 ) in our case , we have tried many ways from using snares to endoscopic biopsy forceps in order to remove the remnant wires . despite all our efforts , upon closing of the procedure , we could remove only a part of the remnant in the ascending aorta .
because the patient refused further trials to remove the remnant wires , we had no choice but to leave the long and thin wire filaments into the proximal circumflex artery and distal lm where drug eluting stents had been deployed . despite triple antiplatelet therapy ,
the result was thrombus formation within the stent at the lm . according to the case
, we conclude that fractured guidewire is one of the most dangerous complications of pci . in similar cases , there are fears that the remnants within a coronary stent could result in stent thrombosis . if removal of such materials percutaneously is impossible , early surgical interventions should be considered .
 during percutaneous coronary intervention , guidewire fractures are very exceptionally encountered in medical practice , but can cause fatal complications such as intracoronary thrombus formation , embolization and perforation . 
 removal of the remnant segments of guidewire is important for the prognosis . 
 there are several methods being recommended for the treatment of fractured guidewire remnants . however , the best treatment of remnant guidewire filament is still unclear . 
 herein , we present a case where we did not completely remove remnant guidewire filaments that caused fatal coronary thrombosis . 