Raiders of the Lost Wire

Introduction: An angiographic guidewire is a basic, yet essential piece of equipment in the interventional cardiologist’s armamentarium. Complications associated with angiographic guidewires can be catastrophic to the safe completion of a coronary procedure. In this article, the authors report a case of angiography guidewire fracture and explore the options for management of this rare but serious complication. Case presentation: A 77-year-old man with multiple cardiovascular risk factors was admitted with an anterior ST segment elevation myocardial infarction. Diagnostic angiography was performed via right radial access and revealed a subocclusive stenosis of the mid and distal left anterior descending artery (LAD) with thrombolysis in myocardial infarction 1 flow and a 70% stenosis of the proximal diagonal branch. Primary percutaneous coronary intervention was attempted and a HI-TORQUE Balance Middle Weight Universal II guidewire (Abbott Vascular Inc., Santa Clara, California, USA) was chosen. Guidewire manipulation was difficult because of significant calcification and tortuosity of the LAD. Consequently, the guidewire fractured and became trapped in the mid-LAD. The complication was ultimately resolved by stenting across the fractured guidewire and the patient was not afflicted by any adverse sequelae. Discussion: This case highlights a rare but potentially serious complication of coronary intervention. Proposed management varies from leaving the fractured wire in situ and stenting across it, to varying techniques for removing the fractured wire. However, no consensus exists as to the best strategy. The authors have therefore performed a review of the current literature and propose an algorithm for the management of this rare complication.