Distal Embolization of Hydrophilic-Coating Material From Coronary Guidewires After Percutaneous Coronary Interventions

Abstract

Background— Coronary guidewires are indispensable during percutaneous coronary interventions. Nowadays, most guidewires have hydrophilic coatings to improve their trackability, allowing easy lesion passage and facilitating balloon and stent positioning. Recent reports, however, have raised concerns about detachment and subsequent embolization of these hydrophilic coatings. Methods and Results— We have retrospectively reviewed the histological samples of the myocardium, obtained during autopsies in the period 2009 to 2013, from all patients who had a history of percutaneous coronary interventions (n=40). Foreign material was observed in the distal myocardium in 4 patients (10%). Furthermore, we have reviewed 205 thrombus specimens which were obtained during thrombus aspiration in the setting of primary percutaneous coronary interventions in the period 2005 to 2009. In 45% of the cases, foreign material was observed within the thrombus. Finally, we have examined the histopathologic appearance of hydrophilic-guidewire coating material ex vivo by embedding the coating in placenta specimen and cut and stain it in exactly the same manner as the myocardium and thrombus specimen. The histopathologic appearance of the hydrophilic coating ex vivo was identical to the foreign material found in vivo. Conclusions— Distal embolization of hydrophilic-coating material was observed in 10% of the patients who had a history of percutaneous coronary interventions. Hydrophilic-coating material was found in 45% of coronary thrombus specimen obtained during thrombus aspiration. These findings suggest that detachment and distal embolization of hydrophilic-coating material from coronary guidewires occur more often than the sparse literature on this topic suggests.

Hydrophilic Polymer Embolism: An Update for Physicians

“…A recent analysis of material captured through use of an embolic protection device during mitral valve repair showed that polymer embolism occurred as frequently as acute thromboembolism (86%), with native tissue emboli (64%) and organizing thrombi (29%) noted less often 18 . Frequent polymer coating emboli have also been affiliated with other percutaneous procedures 19,20 . Thus, polymer embolism should be included in the differential of unanticipated ischemic or inflammatory complications as well as unexplained vasculopathies occurring during the post-procedural clinical setting.…”

Jailing polymer jacketed guide-wires during bifurcation coronary interventions is associated with procedural myocardial infarction

“…Grundeken et al[11] examined the possibility of distal polymer embolization in two ways - they examined the aspirate from patients undergoing aspiration thrombectomy and reported that 45% samples had polymer material in them. Also, examination of autopsy specimens from patients who had undergone PCI showed intramyocardial polymer in 10% subjects.…”

“…Given the retrospective design, this finding should be treated as hypothesis generating and hopefully will trigger prospective analysis to confirm or refute this association. The etiology for this risk is believed to be polymer shearing and micro-embolization which has been proven by multiple small but rigorously conducted studies[11,13]. We believe that much has to be learned about the potential role of polymer shearing and embolization in myonecrosis post CBL intervention.…”

“…However there are concerns over wire damage and shearing of the polymer jacket[8] and hence these are not universally recommended for jailing[9]. In addition, studies of pathological specimens have revealed evidence of embolized polymer in the myocardium[10,11]. Guidewires with no or minimal polymer coatings are felt to be safer but run a risk of wire fracture during attempts at withdrawal[12].…”

Cerebral Granulomatous Inflammation Secondary to Hydrophilic Polymer Embolization Following Thrombectomy

“…Given the widespread use of these procedures, certain complications are becoming more evident, including acute granulomatous inflammatory response to the hydrophilic polymer which often coats the devices used to perform these procedures. This phenomenon has been observed following endovascular interventions in the anterior and posterior cerebral circulation [6–13], pulmonary thrombectomy [14–16], cardiac catheterization [17–20], vascular catheterization with kidney involvement and acute renal failure [21,22], as well as polymer embolization to the skin [23–25] and meninges [26]. This is often an acute response after catheter intervention.…”