LET THE HEART BE YOUR GUIDE: A TALE OF SURGICAL COMPLICATION AND MEDICAL MANAGEMENT

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronary guidewire entrapment and fragmentation during percutaneous coronary intervention is an infrequent complication with incidence between 0.1-0.2%. The retained fragment can lead to flow impediment, vessel thrombosis, distal embolism, and vessel perforation. Complications of guidewire retrieval include developing cardiac tamponade and requiring emergent cardiac surgery. We present a young male with severe multi-vessel disease and a rare procedural complication of coronary guidewire entrapment and fragmentation during percutaneous coronary intervention. CASE PRESENTATION: A 34-year old male with a past medical history for familial hyperlipidemia, hypertension, polysubstance abuse (opiate, benzodiazepine, tobacco, cocaine, alcohol, and marijuana), and hepatitis C presented with intermittent, substernal chest pain with radiation to the left arm. On presentation, patient was hypertensive, and his serum troponin-I peaked at 0.30 ng/mL. LDL was also markedly elevated at 234 mg/dL. His ECG revealed normal sinus rhythm with inferior Q-waves. Myocardial perfusion imaging revealed a medium area of moderate ischemia and infarction in the inferior wall with associated hypokinesis. He underwent coronary angiography which revealed an anomalous left circumflex originating from the right coronary cusp, diffuse right coronary artery disease, and a prior stent in the distal segment with a wire fragment entrapped between the previously deployed stent and the vessel wall. It was later found that this was a complication of his intervention 6 months prior where attempts to remove the wire percutaneously, as well as stenting the retained guidewire against the vessel wall, were all unsuccessful. Thus, the retained wire fragment was left at the stent site. Due to patient's young age and preference, a decision with cardiothoracic surgery was made for medical management to prevent morbidity associated with surgical correction. Patient was started on aggressive medical therapy, educated on substance abuse cessation, and scheduled for close follow-up. DISCUSSION: Risk factors for guidewire fragmentation and entrapment include extensive atherosclerosis of full-length coronary vessel, use of multiple guidewires, and tortuous lesions. Current therapeutic options for coronary guidewire entrapment include percutaneous management, surgical intervention, and conservative follow-up. The management of retained guidewires is not standardized. Percutaneous interventions for retrieval includes utilizing snares, filter wires, or forceps. Conservative management without intervention is indicated for retained guidewires located in small coronary branches with adequate post-occlusion blood flow. CONCLUSIONS: This case demonstrates tailoring therapy. Although, this complication is rare, medical management and lifestyle modification for retained guidewires represents an alternative option to percutaneous intervention. Reference #1: Al-Moghairi, A. and Al-Amri, H., 2013. Management of Retained Intervention Guide-wire: A Literature Review. Current Cardiology Reviews, 9(3), pp.260-266. Reference #2: Karabulut A, Daglar E, Cakmak M., Entrapment of hydrophilic coated coronary guidewire tips: which form of management is best? 2010. Cardiol J. 2010;17(1):104–108. Reference #3: Iturbe J., R. Abdel-karim A., Papayannis A., Mahmood, A., Rangan, B., Banerjee, S., Brilakis, E., 2023. Frequency, Treatment, and Consequences of Device Loss and Entrapment in Contemporary Percutaneous Coronary Interventions. Journal of Invasive Cardiology. 2012; 25(5): 215-221. DISCLOSURES: No relevant relationships by Christopher Bitetzakis, source=Web Response No relevant relationships by Arjun Khadilkar, source=Web Response No relevant relationships by Andrew Mehlman, source=Web Response No relevant relationships by Koushik Reddy, source=Web Response No relevant relationships by Christopher Schwartz, source=Web Response