Intraoperative Monitoring of Movement of an Entrapped Coronary Guidewire by Transesophageal Echocardiography

Abstract

A 64-yr-old man with acute myocardial infarction was referred for emergency percutaneous coronary artery stent placement in the left anterior descending coronary artery and in the first diagonal branch. During the intervention, the deployed left anterior descending stent entrapped the guidewire placed in the first diagonal branch. Efforts to percutaneously retrieve the fragmented wire using a snare wire failed. Preoperative radiograph fluoroscopy images indicated that the proximal end of the fractured wire might be located in the aortic root or the proximal ascending aorta or the proximal aortic arch. The patient’s hemodynamics was stable, and regional as well as global ventricular and valvular function remained unchanged after this event. However, emergency surgery was planned to avoid thrombus formation, prevent embolic events and maintain coronary circulation. The surgical strategy was to establish conventional cardiopulmonary bypass with an arterial cannula inserted into the ascending aorta under anterograde intermittent cold sanguineous cardioplegic arrest with an aortic cross-clamp. The entrapped guidewire was to be manually retrieved after opening the aortic root, followed by coronary artery bypass grafting. As aortic clamping might pinch the wire, the original plan was to temporarily and partially reopen the cross-clamp at the moment of retrieval. Intraoperative transesophageal echocardiography (TEE) located the highly echogenic wire fragment in the ostium of the left main coronary artery and the ascending aorta (Figs. 1A and B; Video Clip 1; please see video clip available at www.anesthesia-analgesia.org), with the proximal end in the distal portion of the aortic arch (Figs. 1B and C). Upon commencement of aortic cannula flow, TEE revealed that the guidewire had migrated backwards toward the aortic root, allowing safe application of the aortic cross-clamp without trapping the wire fragment between the jaws of the clamp. (Figs. 2A and B, Video Clip 2; please see video clip available at www. anesthesia-analgesia.org). Thus, the proximal end of the retained wire was effortlessly retrieved after opening the aortic root. The distal end of the entrapped wire was also easily withdrawn from the coronary artery (Fig. 3). After completion of the coronary bypass, the patient was uneventfully weaned from cardiopulmonary bypass and subsequently recovered without neurological sequelae.