Results
Patient Characteristics
Device loss or entrapment occurred in 13 of 2338 PCIs performed during the study period (0.56%; 95% confidence interval [CI], 0.30%–0.95%). Device loss occurred in 9 cases (0.38%; 95% CI, 0.18%–0.73%) and entrapment in 4 cases (0.17%; 95% CI, 0.05%–0.44%). The baseline characteristics of the 13 device loss or entrapment cases are shown in Table 1. Mean age was 64 ± 10 years and 92% of the patients were men. The patients had a high prevalence of diabetes, hyperlipidemia, hypertension, prior myocardial infarction, and prior PCI. The mean fluoroscopy time and contrast volume used in the device loss/entrapment series was 46 ± 23 minutes and 324 ± 196 mL, respectively.
Device Loss
The lost devices (Table 2) were stents (n = 5; 0.21%; 95% CI, 0.07%–0.50%), a coronary balloon shaft (n = 1; 0.04%; 95% CI, 0.071%–0.24%), a femoral arterial sheath (n = 1; 0.04%; 95% CI, 0.071%–0.24%), an arterial line (n = 1; 0.04%; 95% CI, 0.071%–0.24%), and an Ostial Pro catheter distal tip (n = 1; 0.04%; 95% CI, 0.071%–0.24%). All stents were pre-mounted drug-eluting stents. All patients with device loss were successfully managed percutaneously and only 1 patient experienced periprocedural myocardial infarction. Retrieval of the lost devices was attempted in 7 of 9 cases (78%) and was successful in 6 cases (86%). Retrieval was successful with the initial attempt in 2 patients but required >1 attempt in 4 patients.
Of the 5 stent loss cases, the stent was retrieved in 2 cases and deployed in the other 3 (Table 2). Stent loss was due to tortuosity (1 case), tortuosity and calcification (1 case), and attempts to deliver a stent through previously deployed stents (3 cases). Retrieval was attempted in 3 cases; in 1 case, the small-balloon technique was utilized without success, followed by stent deployment; in a second case, the small-balloon technique and a Microsnare Elite failed, followed by successful retrieval using the "hairpin trap" technique;10 in a third case, snaring with a loop snare failed, but retrieval was successful with an En Snare (Figure 1). In the remaining 2 cases of stent loss, the stents were deployed in the target vessel without attempting to retrieve them.
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Figure 1.
Illustration of stent loss during retrograde total chronic occlusion (CTO) percutaneous coronary intervention (PCI). Antegrade attempts for crossing a mid right coronary artery CTO (A, arrows) failed due to subinitmal wire passage. A Fielder FC guidewire (Abbot Vascular) was advanced retrogradely via a septal collateral over a Corsair catheter (Abbott Vascular). (B, arrow) The Corsair catheter (Abbott Vascular) was advanced distal to the CTO, followed by retrograde true lumen puncture, as confirmed by intravascular ultrasonography. Following retrograde balloon dilatation antegrade wiring was successful and after drug-eluting stent implantation in the right coronary artery TIMI 3 flow was restored (C) Imaging of the left anterior descending artery lesion revealed a lesion (D, arrow) at the site of the crossed collateral. During attempts to treat this lesion, a 2.5 × 28 mm stent was lost in the left main artery (E, arrows) and was snared by a Micro Snare Elite (Vascular Solutions) (F, arrow) but remained partially in the aorta and partially in the left main, as confirmed by intravascular ultrasound (G, arrows). After snaring with an EN Snare (Merit Medical) (H) the stent was successfully retrieved (I, as confirmed by intravascular ultrasound in J). The left anterior descending artery patency was restored after stenting (K).
In addition to the 5 stents, a portion of a femoral sheath, an arterial catheter, a broken balloon shaft, and an Ostial Pro catheter were lost and percutaneously retrieved.
At the end of a procedure, a 7 Fr 45-cm long femoral arterial sheath unraveled during attempts to exchange it for a shorter sheath. After contralateral femoral access was obtained, a 10 mm Gooseneck snare was used to snare and externalize the J-tipped 0.035′ wire, over which the sheath had been inserted. Advancement of a 10 mm Gooseneck snare and an En Snare retrogradely over the externalized guidewire was not possible due to acute aortic bifurcation angle. A snare was created using an Ironman wire (Abbott Vascular) and a diagnostic catheter, allowing successful snaring of the sheath. The unraveled sheath segment was cut and the avulsed sheath segment was successfully retrieved through the contralateral femoral artery. Bilateral iliofemoral angiography did not reveal any vessel injury.
In the second case, a balloon shaft fractured during PCI of a right coronary artery lesion. The distal balloon shaft fragment remained partially in the vessel and partially in the guide catheter and was successfully retrieved using a Gooseneck snare (Figure 2).
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Figure 2.
Illustration of balloon shaft fracture with embolization followed by successful retrieval. During PCI of a 90% mid right coronary artery lesion (A), a 2.7 5mm × 28 mm Maverick balloon (Boston Scientific) shaft became kinked during insertion. The balloon could not be advanced through the lesion and its shaft fractured in two. The distal balloon shaft portion remained in the right coronary artery. A Gooseneck Microsnare (ev3) (B and C, arrowheads) was used to successfully retrieve the distal fragment (B and C arrow, D). Postprocedure angiography confirmed TMI 3 blood flow in the right coronary artery (E).
In a third case, an 18-gauge femoral arterial catheter was incised during attempts to exchange the catheter for a sheath. The catheter fragment embolized to the right peroneal artery and was removed using a Microsnare Elite (Figure 3).
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Figure 3.
Illustration of retrieval of an arterial catheter that embolized into the right peroneal artery. During attempts to exchange a femoral arterial catheter for a femoral sheath, the catheter was accidentally incised and embolized into the right peroneal artery (A, white arrow). Emergency PCI of a proximal acute occlusion of the left circumflex artery was successfully performed. Abdominal aortography revealed an 80% left external iliacartery, 70% left common iliac ostium lesion, and a 50% right common iliac ostium lesion. A Gooseneck Microsnare (ev3) (A, B and C, black arrows) was used to successfully retrieve the distal fragment. Post-retrieval angiography showed normal right popliteal and peroneal arteries with no evidence of dissection or other complication (D). (E) the retrieved catheter is shown next to an intact catheter.
In the fourth case, an Ostial Pro stent positioning system was used in an attempt to stent an ostial saphenous vein graft lesion. During attempts to position the device, its distal portion fractured. The fractured fragment was successfully snared using a loop snare and removed without complications.
Device Entrapment
In contrast to device loss, 3 of 4 patients (75%) with device entrapment required emergency surgical removal and coronary artery bypass grafting. The entrapped devices were coronary guidewires (n = 2), a Filterwire (Boston Scientific), and a Tornus catheter (Abbott Vascular).
In the first entrapment case, a patient underwent stenting of an unprotected left main coronary artery. Both the left anterior descending and the circumflex artery were wired and the left main was stented with a 3.0 x 18 mm everolimus-eluting stent into the left anterior descending artery, jailing the circumflex guidewire. During attempts to remove the jailed circumflex guidewire, its distal trip became entangled with the left main stent, forming a knot (Figure 4D). Multiple retrieval attempts failed and the patient underwent surgical wire retrieval followed by coronary artery bypass graft surgery (Figure 4).
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Figure 4.
Illustration of an obtuse marginal guidewire entrapment following proximal left main artery stent deployment. Diagnostic coronary angiography demonstrated severe left main disease (A, arrow). Both the left anterior descending and the first obtuse marginal arteries were wired. After successful stenting of the first obtuse marginal branch lesion (A, arrow), the left main lesion was stented with a 3.0 × 18 mm stent (C, arrow ). The obtuse marginal artery wire was left in place to allow stabilization during deployment of the left main stent. Attempts to withdraw the obtuse marginal artery wire caused wire entanglement in the stent (D, arrow). Several attempts to remove the wire were unsuccessful (E), requiring surgical intervention (F, G).
In the second case, wire loss occurred when the tip of a Cross-It 100 XT wire (Abbott Vascular) fractured and became entrapped during attempts to cross a chronic total occlusion of the right coronary artery. Attempts to cross the lesion with a Miracle 3 guidewire (Abbott Vascular) resulted in dissection, so the procedure was aborted. Comparison of the retrieved guidewire fragment with an intact guidewire demonstrated that the avulsed segments was <3 cm in length. The device remained embedded in the lesion without other complications.
In the third case, a Filterwire was used during attempts to stent a saphenous vein graft to mid left anterior descending artery. After stenting, the Filterwire could not be retrieved in spite of multiple attempts, requiring surgical removal.
In the fourth patient, a Tornus catheter (Abbott Vascular) became entrapped during attempts to cross a mid right coronary artery chronic total occlusion. Attempts to advance a second guidewire next to the entrapped catheter failed and the patient required surgical removal of the catheter and coronary artery bypass grafting, followed by an uneventful recovery.