44 years old male patient with dyslipidemia, hypertension and heavy smoker. Present with unstable angina diagnosed as TVD refused CABG S/P PCI to LAD with 02DES (SES 3.5* 29 mm and SES 3.0*26 mm) and S/P PCI to proximal to mid RCA  (SES 3.0*29 mm) and failed PCI to CTO mid to distal RCAThis visit he was admitted for elective PCI to CTO mid to distal RCA.Unremarkable physical examination.

BUN   17.0, Cr  0.83, GFR 107Electrolyte: Na 138, K 3.8, HCO3 21, CL 100Anti-HCV, Anti-HIV, HBsAg: negative WBC   8050, Hb 13.5, Hct  40, PLT  245000 PT 12.4, PTT 23.5, INR 1.08 Echo: EF 60%, inferior and inferoseptal wall hypokinesia, no significant valvular abnormalities, no pericardial effusion


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F1786124.mp4

LM: NormalLAD: Patent proximal to mid-LAD stentLCx: No significant stenosisRCA: Patent stent at proximal RCA, CTO mid to distal RCA, receive collateral to PL and PDA from LAD
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Microcatheter (Finecross) with Fielder XT to RCA, unable to pass the CTO lesion then changed to Gaia 2^nd which was unsuccessful too and finally changed to Gaia 3^rd. Gaia 3 rd guidewire got stuck at distal RCA. Snare catheter 8 mm was inserted to retrieve Gaia 3^rd guidewire which was unsuccessful (Several attempts). Turntrac guidewire and Fielder-XT was inserted across the lesion to twist wire for Gaia 3^rd retrieval, but failed and complete fracture of all three wires happened. Snare Size 8 mm was inserted for retrieval but failed.Smaller snare size 7 mm and 4 mm were inserted for retrieval but failed.Left femoral artery puncture with 8 Fr. Sheath. Guiding catheter JR 4.0/7 was used. Snare 8 mm and 15 mm via LFA could retrieve some part of wire. Decided to leave the wire at RCA due to several failed attempts. Angiogram was done before stopping the procedure. As we were removing the catheter, thin stretched guidewires were seen floating in the ascending aorta till descending aorta. Snare 15 mm could remove the wire floating in the aorta after several attempts.Final angiogram showed retained some parts of fractured guidewires and planned to leave it there. The patient was asymptomatic and hemodynamically stable.




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Retrieving second fracture wire.mp4
Wire Floating in aorta.mp4

1.   Factors that predispose to guidewire fracture include severe vessel calcification, sharp side branch angulation, excessive wire manipulation, and variations in wire length or thickness2.    Guidewire is thrombogenic and its presence inside the coronary or hanging up into the aorta may carry a risk of thrombo-embolization, making its removal essential.3.    Strategies for retrieval of fractured guidewire includes snaring, multiwire technique, trapping techniques, stenting, surgical removal or leaving the corpus alienum in-situ. 4.    GooseNeck snare is a feasible approach for retrieving a lost guidewire confined to proximal coronary artery.