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CARDIOVASCULAR ANESTHESIOLOGY

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

From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Address correspondence and reprint requests to Yasufumi Nakajima, MD, PhD, Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan. Address e-mail to nakajima{at}koto.kpu-m.ac.jp.

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.

View larger version (59K): [in this window] [in a new window]   Figure 1. Echogenic remnants entrapped in the left main coronary artery. Guidewire undulates from the ascending aorta towards the distal portion of the aortic arch. (A) mid-esophageal aortic valve short axis view; (B) mid-esophageal aortic valve long axis view; (C) transition between upper-esophageal aortic arch long axis and mid-esophageal descending aorta short axis view. gw = fragmented guidewire; AoA = aortic arch; LMCA = left main coronary artery.

View larger version (97K): [in this window] [in a new window]   Figure 2. (A) Fractured guidewire discovered in the aortic arch before cardiopulmonary bypass. (B) Fragmented guidewire was displaced immediately after onset of cardiopulmonary bypass towards the proximal aortic arch. (upper-esophageal aortic arch long axis view). AoA = aortic arch.

View larger version (180K): [in this window] [in a new window]   Figure 3. Retrieved guidewire of about 40 cm. Core wire (solid arrow) has broken and fine surrounding wire (blank arrow) has become elongated.

DISCUSSION

Coronary artery dissection, hemopericardium, and acute coronary thrombosis are the usual indications for emergency surgery after failed percutaneous coronary interventions. Although rare, guidewire remnants can occasionally become entrapped within the coronary circulation or the aorta and require emergency surgery. Reports describing catheter remnants (guidewire, stent, Rotablator) entrapped in coronary arteries are sparse. Thus, the incidence and clinical outcome remain obscure. One large observational study disclosed that, of 118 patients who required emergency coronary artery bypass grafts during percutaneous coronary angioplasty, one was due to a retained guidewire.1 Another case series described that the incidence of angioplasty hardware entrapment or fragmentation is 0.2%–0.8% and that 15%–20% of these patients require emergency surgical management,2,3 the optimal choice of which remains unknown. However, one study has proposed an algorithm for managing such patients. When a portion of a guidewire is entrapped in the coronary system, the remnants should be retrieved percutaneously. If this fails, prompt surgical coronary revascularization of the affected vessel should be considered. A TEE examination should determine whether the proximal portion of the wire or catheter is located in the aortic root or proximal aorta. When the retained wire or catheter cannot be easily retrieved, amputation deep in the coronary ostium to prevent future thrombus formation, or retrieval through coronary arteriotomy should be considered.2 Whether to leave or remove remnants depends on their location and size, and the size of the coronary artery. Although the risk of catheter remnant embolization is low, the catheter remnants present a nidus for thrombus formation and subsequent embolization to cerebral and other peripheral vessels. The prognosis after surgery is primarily determined by preoperative clinical status. The incidence of postoperative morbidity (e.g., myocardial infarction, cerebrovascular accidents, renal failure, and respiratory failure) can be significant. Thus, early surgical management by coronary artery bypass grafting decreases mortality rates among patients with complications.

Although the diagnostic sensitivity and specificity of TEE for the linear image in the aorta (e.g., aortic dissection, foreign body) is high, the reported incidence of linear artifacts in the ascending aorta by TEE varies from 44% to 55% in patients with suspected acute aortic events.4 Linear artifacts have three typical locations and mobility patterns related to the posterior wall of the aorta or the right pulmonary artery according to M-mode and 2-dimensional echocardiography.4 For instance, the characteristic anatomical features (ascending aortic diameter >5 cm and atrial-aortic diameter ratio <0.6) create conditions for reverberation of the atrial-aortic interface within the aorta.5 Thus, echocardiographic linear images, especially in the ascending aorta, should be differentiated from intraluminal linear artifacts by precise interpretation. The diagnostic specificity of linear echocardiographic images can be improved by the more concrete diagnostic criteria that linear artifacts have characteristic features, such as displacement of the linear image parallel to aortic walls, similar blood flow velocities on both sides of the linear image, a linear image thickness of >2.5 mm, and an angle between the linear image and the aortic wall of >85°.5 These interrogations should be conducted in more than one view by multiplanar TEE.

Our experience with this patient showed that the intraoperative multiplanar TEE examination was useful in demonstrating the presence and assessing the full extent of a guidewire that had become entrapped during surgery and migrated, thus allowing safe application of the aortic cross-clamp and accurate guidance of the efforts to surgically retrieve the guidewire fragments.

Footnotes

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication May 23, 2008.

REFERENCES

1. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation 2002;106:2346–50[Abstract/Free Full Text]
2. Chang TM, Pellegrini D, Ostrovsky A, Marrangoni AG. Surgical management of entrapped percutaneous transluminal coronary angioplasty hardware. Tex Heart Inst J 2002;29:329–32[Web of Science][Medline]
3. Alexiou K, Kappert U, Knaut M, Matschke K, Tugtekin SM. Entrapped coronary catheter remnants and stents: must they be surgically removed? Tex Heart Inst J 2006;33:139–42[Web of Science][Medline]
4. Evangelista A, Garcia-del-Castillo H, Gonzalez-Alujas T, Dominguez- Oronoz R, Salas A, Permanyer-Miralda G, Soler-Soler J. Diagnosis of ascending aortic dissection by transesophageal echocardiography: utility of M-mode in recognizing artifacts. J Am Coll Cardiol 1996;27:102–7[Abstract]
5. Vignon P, Spencer KT, Rambaud G, Preux PM, Krauss D, Balasia B, Lang RM. Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption. Chest 2001;119:1778–90[Web of Science][Medline]

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