Fatal Subacute Stent Thrombosis Induced by Guidewire Fracture with Retained Filaments in the Coronary Artery
A 72-year-old woman was referred from another hospital for coronary intervention of distal left main disease. The patient suffered from resting chest pains and dyspnea for over a month. She had no other risk factors besides old age. The electrocardiogram (ECG) showed normal sinus rhythm without any changes in abnormal ST segment. Cardiac enzymes were within normal range. The transthoracic echocardiography showed normal left ventricular systolic functions without regional wall motion abnormalities.\nHer left coronary angiogram (CAG) showed tight luminal narrowing at the distal left main coronary artery (LM) with preserved distal coronary flows {Thrombolysis in Myocardial Infarction (TIMI) grade 3} (). The left coronary artery was engaged with the Extra Back Up (EBU) 3.5 guiding catheter (6 Fr, Medtronic, Minneapolis, MN, USA) with side hole via right radial artery. Two 0.014 inch guidewires were positioned into the left anterior descending artery (LAD) (Balanced Middle Weight, Abbott Vascular, Santa Clara, CA, USA) and the left circumflex artery (LCX) (Runthrough, Terumo, Tokyo, Japan). Predilatation and balloon kissing were done with 2.5×20 mm balloon (Trek, Abbott Vascular, Santa Clara, CA, USA) in LAD up to 12 atm and 2.0×20 mm balloon (Genoss, Suwon, Korea) in LCX up to 10 atm. We implanted a 2.75×18 mm everolimus-eluting stent (Xience Prime, Abbott Vascular, Santa Clara, CA, USA) at the proximal segment of LCX with minimal protrusion into the LM, and which was crushed using 2.5×20 mm Trek balloon. We also deployed a 3.0×18 mm everolimus-eluting stent (Xience Prime, Abbott Vascular, Santa Clara, CA, USA) from the LM trunk to the proximal segment of LAD across the ostium of LCX. We were about to insert intravascular ultrasound (IVUS) catheter into the LCX after successful re-wiring into the LCX with Runthrough guidewire, and then, we realized that the guidewire was kinked at small branch of LCX (). We tried to remove the guidewire by pulling and rotating softly. Even though the wire was broken at the junction of hard shaft and soft wire tip, we could see the elongated and uncoiled wire remnant swinging in the ascending aorta on cine view ().\nWe changed guiding catheter for a bigger one (7 Fr, EBU) via right femoral approach. Several attempts for removal of remnant wire by using Amplanz GooseNeck snare (6 Fr, 15 mm, Loop Snare catheter, ev3, Plymounth, MN, USA) was not successful (). We tried again by using endoscopic biopsy forceps (6 Fr, 1550 mm, Olympus, Tokyo, Japan) (). Eventually, we caught the broken wire and could remove a part of the wire (), leaving the soft tip in the small branch (). The radiopaque remnant was fixed to the vessel wall by an additional stent implantation (2.75×23 mm, Xience Prime, Abbott Vascular, Santa Clara, CA, USA). Final angiographic results were good. Elongated and un-coiled filaments were not seen within LM and proximal LCX on cine view. However, the uncoiled filaments were identified within the distal LM and proximal LCX on IVUS (). The patient strongly declined a surgical removal of the remnants. Glycoprotein IIb/IIIa inhibitor was administered to the patient. After seven days, the patient was discharged with triple antiplatelet agents including aspirin, clopidogrel, and cilostazol.\nFour days later, the patient revisited the emergency department with acute chest pain in shock state. ECG showed ST-segment elevation in lead aVR and aVL and ST-segment depression in lead II, III, aVF, and V 4-6. Shortly afterwards ventricular tachycardia was developed and we performed cardiopulmonary resuscitation immediately. Percutaneous cardiopulmonary support (PCPS) was applied at the bed side right away, and then, the patient was sent to the coronary catheterization laboratory. Bed side echocardiography demonstrated severe LV systolic dysfunction with about 20% of the ejection fraction.\nEmergency CAG was performed immediately and it revealed that LM was totally occluded due to subacute stent thrombosis (). We inserted intra-aortic balloon pump. The TIMI flow was recovered to grade II after aspiration thrombectomy and balloon angioplasty at LM (3.0×20 mm, Ruyjin, Terumo, Tokyo, Japan) and LCX (2.5×20 mm, Trek). Finally, the kissing balloon procedure was followed.\nAfter recovery of coronary flow, the patient's heart function seemed to improve echocardiography gradually. On the 6th hospital day, weaning from PCPS was successfully, however, the patient was in septic condition, with decreasing courses due to unknown bacterial or fungal infections. Disseminated intravascular coagulation was getting worse and acute renal failure was not improving despite the continuous renal replacement therapy. Eventually, we lost the patient on the 15th hospital day.