By Ajar Kochar, MD, MHS, FSCAI; Sripal Bangalore, MD, MHA, FSCAI; Kevin Croce, MD, PhD, FSCAI

Introduction

Entrapped coronary equipment is a rare but potentially life-threatening percutaneous coronary intervention (PCI) complication. Devices at risk include coronary guidewires (the most commonly entrapped device in chronic total occlusion [CTO] PCI), balloons, microcatheters, guide extenders, rotational/orbital burrs, and stents.¹ The ramifications of device entrapment include coronary perforation, dissection, thrombosis, and both peri-procedural and late myocardial infarction.² Risk factors for this complication include lesion characteristics (e.g., severe calcification and extreme tortuosity/angulation), procedural techniques (e.g., excessive torque, over-rotation of a microcatheter, inadequate pecking motion, and retrograde approaches), and device issues (e.g., microcatheter fatigue). A systematic approach — pulling/telescoping, trapping, snaring, and bailout (crushing/surgery) — allows operators to percutaneously salvage entrapped equipment with a high degree of success (80%-90%).¹

Pulling & Telescoping

Initial traction is often the first step, but it is associated with a risk of further device separation, dissection, and perforation.

• For stripped stents with a wire still through the lumen, a small balloon (1.5 mm x 20 mm balloon, uninflated diameter < 0.6 mm) can be advanced distal to the stent, inflated, and withdrawn into the guide. Alternatively, the twisted wire strategy can employ a second or even a third wire guided through a strut of the stent. Then, a torquer is advanced over the two to three wires and twisted 15-20 times until the wires are visibly intertwined near the proximal end of the stent, at which point the entire system can be removed.³
• Rarely, balloons may not deflate; the most common cause is a kink in the balloon hypotube. Solutions include (i) changing contrast for saline, (ii) intentionally rupturing the balloon with high pressure (30 atm-40 atm), (iii) puncturing the balloon with a stiff CTO wire or back end of a coronary wire, and (iv) cutting the proximal hypotube to resolve the kink.⁴
• Regarding jailed guidewires behind stents, a microcatheter or over-the-wire balloon (OTB) can be advanced to the proximal edge of the pertinent stent, followed by spinning the wire quickly, and applying gentle backward traction while avoiding excessive force that may fracture or unravel the wire.
• For rotational and orbital atherectomy burrs, the drive shaft can be cut close to the control panel and the protective plastic sleeve removed. Then, a guide extender should be advanced over the drive shaft to the stuck burr. The Rotawire/Viper wire, which is 0.014” at the distal tip, can be pulled with some forward counter traction on the guide extender to dislodge the stuck burr. Alternatively, a second wire can be advanced parallel to the stuck burr, and a small balloon over this new wire can be employed to free up the lodged device. Finally, a mini subintimal tracking and reentry (STAR) strategy may be employed to loosen the entrapped burr via serial balloon dilations in the subintimal space.⁵

Trapping

For devices that are separated, a guide extender can be advanced close to or even over the dislodged equipment. A long balloon inflated in the guide extender can trap the equipment against the guide extender wall and then removed en bloc. Regarding equipment that is entrapped but still intact, operators can use a balloon (2.0 mm x 20 mm for 6F, 2.5 mm x 20 mm for 7F) within the distal end of the guide to increase the radial withdrawal force when applying backward traction to the entire system together.

Snaring

The only snare designed for an 0.014” wire compatibility is the MICRO Elite Snare (Teleflex^TM), which has a radiopaque platinum toil and a helical loop design for a longer reach. For the coronary space, operators can also use the 2 mm- to 4 mm-sized EN Snare (Merit Medical) system with three interlaced nitinol loops and the Goose Neck microsnare kit (Medtronic) with a 90⁰ gold-plated tungsten loop.

The snare often needs to be retracted into an introducer and then advanced through an accompanying microcatheter (alternatively, a guide extender/guide can be used for countertraction). The snare can be loaded on a guidewire and advanced to the retained equipment. The snare is “de-sheathed” to allow it to be fully exposed. Operators should then try and align the snare with the entrapped equipment and pull the snare back against the microcatheter/guide extender/guide to generate counterpressure. Depending on the snare, a locking mechanism can secure the snare in place or tension can be maintained manually.

Note, if a snare cannot be successful employed, operators may consider the careful use of a myocardial bioptome; pediatric-sized bioptomes are preferable.

Bailout

If retrieval is unsuccessful, operators can crush the entrapped item (stent, balloon, microcatheter tip, wire) against the coronary wall with a new stent; however, there is an increased risk of stent thrombosis with a crushing strategy, so extended dual antiplatelet therapy (DAPT) should be considered. In the absence of percutaneous solutions, surgical management is also an option.

Additional considerations:

• Force optimization: Reduce the distance and increase the focused/coaxial force to remove an entrapped item by telescoping a microcatheter (guidewire) or a guide extender deeply engaging a guide (balloon, stent, burr).
• Anticoagulation/antiplatelets: Maintain adequate anticoagulation and antiplatelets (e.g., Cangrelor) to minimize the risk of compounding intracoronary thrombosis.
• Lubrication: Inject Rotaglide or ViperSlide solution via the guide to help lubricate the coronary artery/entrapped equipment, decrease friction, and increase the likelihood of successful retrieval.
• Stent deployment: If wire access remains and stent-vessel sizing is acceptable, deploy the stent in situ. If there is a large stent-vessel size mismatch, operators can inflate a balloon proximal to the stent, push the stent more distal, and deploy the stent in a more appropriately sized vessel segment.
• Integrity: Check the integrity of the retrieved item to ensure no retained/broken pieces are left in vivo.

References

1. Gasparini GL, Sanz-Sanchez J, Regazzoli D, et al. Device entrapment during percutaneous coronary intervention of chronic total occlusions: incidence and management strategies. EuroIntervention. 2021 Jun 25;17(3):212-219.
2. Sanz-Sanchez J, Mashayekhi K, Agostoni P, et al. Device entrapment during percutaneous coronary intervention. Catheter Cardiovasc Interv. 2022 Mar 21;99(6):1766-1777.
3. Devidutta S, Lim ST. Twisting wire technique: An effective method to retrieve fractured guide wire fragments from coronary arteries. Cardiovasc Revasc Med. 2016 Jun;17(4):282-6.
4. Watt J, Khurana A, Ahmed JM, Purcell IF. Simple Solution for an Undeflatable Stent Balloon in the Left Main Stem. JACC Cardiovasc Interv. 2015 Dec 21;8(14):e245-6.
5. Sulimov DS, Abdel-Wahab M, Toelg R, et al. Stuck rotablator: the nightmare of rotational atherectomy. EuroIntervention. 2013 Jun 22;9(2):251-8.