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INTERNAL CAROTID PSEUDOANEURYSM CAUSED BY MIGRATION OF A CORONARY GUIDEWIRE FRAGMENT: A CASE OF A BROKEN ARROW

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Resumo:	Introduction: Guidewire fracture is a rare complication of percutaneous coronary intervention (PCI). Retained fragments can cause thrombosis, dissection, perforation of the vessel or embolize. When is impossible to withdraw or to trap the fragment during the procedure, management is debatable between surgical removal or conservative approach. When choosing to leave the fragment in place, the patient remains at risk for all of the aforementioned complications.  Clinical Case: 65-year-old male patient submitted to PCI with stenting of distal right coronary artery in 2017. A proximal optimization technique was performed, with a guidewire placed in the posterior descending artery (PDA). After stenting, the protection guidewire became entrapped and after several retrieval attempts, it fractured. Wire fragment remained within the RCA and ascending aorta with a free mobile distal part in the beginning of the innominate artery. Multiple attempts went in vain for wire retrieval and a conservative approach was adopted. Two and a half years later, the patient felt a sudden chest pain and then collapsed. He was transferred to our Hospital for emergent surgery due to cardiac tamponade. Intra-operatively, cardiac surgeons found the guidewire perforating the posterior descending artery. When trying to pull it out, the guidewire fractured again. Post-intervention CTA revealed migration of the fragmented guidewire now it was entrapped in a tortuous initial portion of the right internal carotid artery and a small pseudoaneurysm was visible at the distal portion of the wire. Surgical approach was performed revealing the presence of the wire within the carotid medial wall, in a subintimal plane. The 7 cm fragment was successfully withdrawn, through a common carotid transverse incision. Pseudoaneurismectomy was performed and carotid artery bifurcation reconstruction with internal carotid artery re-implantation into the bifurcation, end-to-end anastomosis. The patient had an uneventful postoperative course.  Conclusion: Although leaving the wire in place remains an option, coronary guidewire fractured fragments can be associated not only with immediate complications but also with potential adverse events in the long run.
Assunto:	foreign body in ascending aorta fratura de fio-guia cardiac tamponade complicações da intervenção coronária percutânea guidewire embolization tamponamento cardíaco pseudoaneurisma da artéria carótida interna percutaneous coronary intervention complications internal carotid pseudoaneurysm broken guidewire migração de fio guia
País:	Portugal
Tipo de documento:	journal article
Tipo de acesso:	Restrito
Instituição associada:	Angiologia e Cirurgia Vascular
Idioma:	inglês
Origem:	Angiologia e Cirurgia Vascular

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conditionsOfAccess_str	Copyright (c) 2020 Angiologia e Cirurgia Vascular
contentURL_str_mv	http://acvjournal.com/index.php/acv/article/view/319/208 http://acvjournal.com/index.php/acv/article/view/319
country_str	PT
description	Introduction: Guidewire fracture is a rare complication of percutaneous coronary intervention (PCI). Retained fragments can cause thrombosis, dissection, perforation of the vessel or embolize. When is impossible to withdraw or to trap the fragment during the procedure, management is debatable between surgical removal or conservative approach. When choosing to leave the fragment in place, the patient remains at risk for all of the aforementioned complications.  Clinical Case: 65-year-old male patient submitted to PCI with stenting of distal right coronary artery in 2017. A proximal optimization technique was performed, with a guidewire placed in the posterior descending artery (PDA). After stenting, the protection guidewire became entrapped and after several retrieval attempts, it fractured. Wire fragment remained within the RCA and ascending aorta with a free mobile distal part in the beginning of the innominate artery. Multiple attempts went in vain for wire retrieval and a conservative approach was adopted. Two and a half years later, the patient felt a sudden chest pain and then collapsed. He was transferred to our Hospital for emergent surgery due to cardiac tamponade. Intra-operatively, cardiac surgeons found the guidewire perforating the posterior descending artery. When trying to pull it out, the guidewire fractured again. Post-intervention CTA revealed migration of the fragmented guidewire now it was entrapped in a tortuous initial portion of the right internal carotid artery and a small pseudoaneurysm was visible at the distal portion of the wire. Surgical approach was performed revealing the presence of the wire within the carotid medial wall, in a subintimal plane. The 7 cm fragment was successfully withdrawn, through a common carotid transverse incision. Pseudoaneurismectomy was performed and carotid artery bifurcation reconstruction with internal carotid artery re-implantation into the bifurcation, end-to-end anastomosis. The patient had an uneventful postoperative course.  Conclusion: Although leaving the wire in place remains an option, coronary guidewire fractured fragments can be associated not only with immediate complications but also with potential adverse events in the long run.
documentTypeURL_str	http://purl.org/coar/resource_type/c_6501
documentType_str	journal article
id	7ec3c2df-cb62-453b-8ac7-425512bb4493
identifierDoi_str	https://doi.org/10.48750/acv.319
language	eng
relatedInstitutions_str_mv	Angiologia e Cirurgia Vascular
resourceName_str	Angiologia e Cirurgia Vascular
spellingShingle	INTERNAL CAROTID PSEUDOANEURYSM CAUSED BY MIGRATION OF A CORONARY GUIDEWIRE FRAGMENT: A CASE OF A BROKEN ARROW foreign body in ascending aorta fratura de fio-guia cardiac tamponade complicações da intervenção coronária percutânea guidewire embolization tamponamento cardíaco pseudoaneurisma da artéria carótida interna percutaneous coronary intervention complications internal carotid pseudoaneurysm broken guidewire migração de fio guia
title	INTERNAL CAROTID PSEUDOANEURYSM CAUSED BY MIGRATION OF A CORONARY GUIDEWIRE FRAGMENT: A CASE OF A BROKEN ARROW
topic	foreign body in ascending aorta fratura de fio-guia cardiac tamponade complicações da intervenção coronária percutânea guidewire embolization tamponamento cardíaco pseudoaneurisma da artéria carótida interna percutaneous coronary intervention complications internal carotid pseudoaneurysm broken guidewire migração de fio guia