56 years old male patient presented to our clinic with Canadian Cardiac Society (CCS) Class II stable angina pectoris that has been continuing for 6 months. His past medical history revealed hypertension and hyperlipidemia. Myocardial perfusion scintigraphy demonstrated inferior ischemia and diagnostic coronary angiography showed chronic totally occluded (CTO) right coronary artery (RCA) (Fig 1.) We planned balloon angioplasty and stenting to RCA-CTO.
Procedure
Due to absence of microchannels we chose to start with Corsair microcathater (Asahi, Intecc) and Conquest pro (Asahi, Intecc) guidewire. The guidewire went subintimally and caused dissection, we tried to take the guidewire but it was trapped and we had difficulty pulling out the guidewire. With forcefull traction we were able to take it back, but we saw that it was broken from the tip and the tip of the guidewire was still in the subintimal space (Fig 2). Since the patient did not have any symptoms and there weren’t any signs of perforation. We decided to leave this guidewire subintimally and went on the procedure with another conquest pro guidewire. We were able to cross the lesion with the second guidewire and stent was successfully deployed without any complication (Fig 3).
What wolud you do if you were ??
Dear Ersan ,
As a Vascular and Endovascular surgeon I do not work with chronic totally occluded (CTO) in the heart, however we tdo CTO peripheral arterial disease and when it is possible we use loop tecnics with the wires or the The Amplatz GooseNeck® Snare . The snare is constructed of Nitinol cable and a gold plated tungsten loop. The pre-formed snare loop can be introduced through catheters without risk of snare deformation because of the snare’s super-elastic construction .
In your case you did a wonderful job in my opinion, leaving the guidewire subintimally and going on the procedure with another conquest pro guidewire! Congratulation!
Dear Dr. Tatli,
This is an interesting presentation, thank you for sharing. As Dr. Ocke Reis stated above, we, in our center, would also have used a snare to remove the fragmented piece of wire.
Great work all in all!
Dear Dr. Tatli,
This is an interesting presentation, thank you for sharing. As Dr. Ocke Reis stated above, we, in our center, would also have used a snare to remove the fragmented piece of wire.
Great work all in all!
Interesting case. In our practice we will sometimes attempt to remove a fragmented piece of wire with a small gooseneck snare. However this wire is in the sub-intimal space and you could cause more complication by attempting to remove it. Personally I would stent the occlusion and leave the broken wire tip alone. I have seen a couple of cases where guidewire tips have been left in situ without inducing a clinical event either short or long-term. Should be fine to be left in situ.
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