Abstract:
Guidewire entrapment is a rare and unreported complication in cerebrovascular endoluminal interventions, which is difficult to manage and may lead to fatal consequences. To summarize the four cases of guidewire ingrowth complications that occurred in our center in 2007, we analyzed the causes and discussed feasible countermeasures in light of the literature.
Discussion.
It has become a consensus among neurologists that interventional surgical interventions can benefit some patients with cerebrovascular diseases under the premise of strict selection of indications [1,2], and even in some cases (e.g., deep cerebral vascular malformations, posterior circulation intracranial aneurysms, partial posterior circulation ischemia), interventional surgery has become an irreplaceable treatment modality [3,4]. However, it is undeniable that surgical operations involving intracranial vessels are always associated with considerable risks, and reports of surgical complications are by no means rare in the literature [5,6,7]. However, there are no specific reports on “guidewire impaction”, and the author summarized four cases that occurred in the past four years, all of which were relatively serious surgical complications, although the final clinical outcome of some patients was acceptable. Bai satellite, Department of Interventional Medicine, Henan Provincial People’s Hospital
The four cases of guidewire embedding in this article, all of which occurred in the context of cerebral artery stent placement, should first be reviewed for operation. According to the author’s understanding, either because of the operator’s confidence in the operation or to reduce the cost of the procedure for the patient, many doctors in China perform stenting of the intracranial arteries by guiding the head section of the exchange guidewire (Transend300Floppy, BSC, US) through the stenotic vessel by a balloon catheter after a slight shaping. It has been shown that this may lead to the occurrence of guidewire impaction. For one reason, due to the poor guidance of the balloon catheter, the tip of the exchange guidewire must not be too curved, otherwise it will not be easy to pass through the stenotic vessel; for another reason, due to hemodynamic factors, the vessels far from the stenotic segment are often poorly visualized, and it is not possible to detect in time that the guidewire has entered a small branch after crossing the stenotic segment. In addition, all four cases of guidewire embedment were with Transend300Floppy, which cannot be completely ruled out as a defect in product design and production. As an exchange guidewire, the Transend300Floppy is 300 cm long, with the proximal section made of stainless steel and the distal section made of nickel-titanium alloy material, with a platinum ring wrapped around the first 3 cm to ensure visibility. The physical characteristics of this guidewire are determined: good propulsion and plasticity, poor torsion, lack of smoothness of the head section, and easy to kink. The above characteristics may be related to the occurrence of ingrowth of the guidewire.
3 How to deal with and prevent it It should be said that once the ingrowth of the guidewire occurs, it is very difficult to deal with. The author has tried a variety of measures, including: local instillation of poppy bases or nimodipine needles through the catheter, suspension of the operation for observation, etc., but none of them can make the guidewire withdraw smoothly. Slow and persistent traction may be possible to withdraw the guidewire, but there is a high risk of vascular rupture and bleeding, or even life-threatening. In comparison, repeatedly rotating the guidewire until the head section of the guidewire kinks is a proven treatment, although the residual guidewire in the body requires long-term intensive antithrombotic medication and blockage of small branch vessels may lead to cerebral ischemic events. Of course the best treatment is not as effective as prevention, and the author suggests two things. First, choose materials that do not go beyond the instructions for use as much as possible. As in case 1, Wingspan stent is designed and produced for lifting intracranial atherosclerotic stenosis, with good through performance and radial support, but applied in aneurysm stent-assisted technology, and specialized stent Neuroform seems to have no advantage compared to it. Second, do not blindly reduce the operating procedure. Especially for patients with tortuous target vessels, the author recommends the application of conventional microguidewires (such as Transend softip or Silverspeed) to introduce conventional microcatheters (such as Excelsior or Echlon) into the distal branches of the target vessel, and then introduce exchange guidewires (which can be shaped into a “J” or “U” shaped), followed by the introduction of a balloon catheter or stent, minimizes the risk of wire entrapment.
References (omitted)