Case 164: Manual of PCI - Wire fracture

A patient with prior TAVR with a Sapien valve was referred for PCI due to angina. He had left main as well and mid and distal RCA heavily calcified lesions. We decided to first perform PCI of the RCA lesions. Right heart catheterization showed a right atrial pressure of 7 mmHg and pulmonary artery pressure of 41/15 mmHg, hence no hemodynamic support was used. We wired the RCA with a workhorse wire but a Turnpike Spiral and Turnpike LP microcatheter could not cross the mid RCA lesion. We removed the workhorse wire and were able to advance a Viper Flex tip wire to the right PDA. Multiple rounds of orbital atherectomy were performed. The Viper Flex tip wire became twisted distally and could not be withdrawn. We advanced the Turnpike catheter to the distal segment of the Viper wire and were then able to retrieve the wire but the tip fractured and remained in the vessel. IVUS did not show wire unraveling and comparison with a new Viper Flex tip wire showed that the fracture was at the distal 3 cm. We did multiple retrieval attempts using the “knuckle twister” technique, twirling wires and snares (Gooseneck and 2-4 mm EnSnare) without success. We abandoned wire retrieval efforts and predilated and stented the right coronary artery, trapping the wire fragment behind the stent struts with a nice final result. The left main intervention was staged for a later date.