U.M.

A 92-year-old male presented with typical angina on exertion and recurrent biventricular heart failure 4 episodes in the past 6 months. He had history of double vessel disease and underwent percutaneous coronary intervention (PCI) with an Everolimus-eluting stent at proximal right coronary artery (RCA) 4 years ago. He also had hypertension, hyperlipidemia. Physical examination showed normal vital signs and diastolic rumbling murmur grade III/VI at the apex.

ECG 12 leads showed normal sinus rhythm with frequent premature atrial complex and pathologic Q wave at lead III. Echocardiography showed normal left ventricular systolic function with ejection fraction of 60% and basal to apical inferior wall hypokinesia with preserved systolic motion thickening. Laboratory findings were within normal limits.

No in-stent restenosis at proximal RCA and borderline significant coronary artery stenosis at mid RCA. Physiologic study was performed at RCA, RFR 0.98, a resting FFR 0.97 and a maximum hyperemia FFR of 0.89, PCI at RCA was deferred. There was a chronic total occlusion (CTO) at mid LAD with bridging collateral circulation from septal branch of LAD. PCI of CTO at mid LAD was performed after team discussion for benefit, likelihood of successful PCI (J-CTO score of 2) over peri-procedural risks.

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A 6-Fr system sheath with XB3 guiding catheter was accessed via the right femoral artery without dual injection. Antegrade wire escalation technique with microcatheter was used but failed to Pilot 50 and Fielder XT. Conquest Pro could successfully pass the CTO lesion, but the microcatheter could pass through just proximal to the CTO lesion. Then, the Rotawire Floppy was used, and successful Rotablator atherectomy was done with Rotalink Burr 1.25 mm, speed 180,000 RPM for 4 times. During the procedure, the distal Rotawire showed deformity and entrapment. Rotawire removal was attempted via distally microcatheter inserted and gently pull back. Meanwhile, the distal Rotawire got fracture and loss in the distal part of LAD. The multiwire twirling technique was used with Pilot-50 and Samurai guidewire in the same torquer and twist. Most of the Rotawire fragments were successfully retrieved; however, a small Rotawire fragment was retained in a small side branch of distal LAD. PCI with Sirolimus-Eluting stent was successfully done at proximal to mid LAD. The final coronary angiogram showed no coronary perforation or coronary blood flow limitation at LAD. Follow up, the patient has improvement in anginal pain and no recurrence of heart failure symptoms.
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Although it is infrequent and often preventable, Guidewire entrapment and loss can potentially cause coronary thrombosis and subsequent myocardial infarction. In case of difficulty in retrieving, recommendations suggest not to manipulate aggressively. Multiple techniques were attempted to manage intracoronary guidewire loss up to the location of retained guidewire fragment, such as the multiwire twirling technique, retrieving with the microsnare, and fixing with an additional stent. However, it could be left with closed observation when the retained fragment was small and located in the distal coronary artery.