Surgical management for retained distal embolic protection device and fractured guidewire after carotid artery stenting

Abstract

Entrapment and fracture of carotid angioplasty and stenting hardware is a rare complication of percutaneous stenting procedures. We describe a case of a retained distal filter embolic protection device and guidewire in a 57-year-old male in Beijing, China. After unsuccessful attempts at removal via interventional methods, a second stent was deployed to secure the original hardware in situ, and the patient was discharged. He later experienced guidewire fragmentation in the carotid artery and aortic arch, with subsequent thrombus formation. We report partial removal of the guidewire and stent via carotid artery cutdown and open thoracotomy without complication. When efforts to retrieve stenting hardware are unsuccessful, it is never a suitable choice to leave them within the artery. We advocate for early surgical management of retained materials after unsuccessful carotid artery stenting. Furthermore, improved quality monitoring and assurance programs are needed to prevent such complications in the future.

Figure 1:

(a) Digital Subtraction Angiography of patient prior to angioplasty with 90% stenosis of the ICA. (b) Fractured guidewire when patient presented to our facility. The EPD cannot be clearly seen. (c) Reconstructed CT image in anterior view showing the 3 guidewire fragments (Fragments A, B, C) and the 2 carotid stents (Stent 1 and Stent 2) in the right ICA. (d) Reconstructed CT image in the right lateral view of guidewire fragments and stents.

Figure 2:

(a) The inferior aspect of Fragment C extended down to the femoral artery. (b) The superior aspect of Fragment C penetrated the thoracic aorta.

Figure 3:

(a) Guidewire fragments and Stent 1 after removal from the patient. (b) CT image showing patent vasculature at 30 months post-operation.