Description of Event or Problem · 1
DURING CORONARY ANGIOPLASTY A BOSTON SCIENTIFIC GUIDE WIRE WAS USED TO CANNULATE THE OBTUSE MARGINAL CORONARY ARTERY. THE VESSEL WAS DILATED. UPON ATTEMPT TO REMOVE THE GUIDEWIRE, A WIRE FRAGMENT SHEARED OFF. A SECOND CARDIOLOGIST THEN CANNULATED THE SAME VESSEL WITH A DIFFERENT SIZE BOSTON SCIENTIFIC GUIDEWIRE FOR AN ATTEMPT TO RETRIEVE THE FRAGMENT. WHEN UNABLE TO ACCOMPLISH, THE DECISION WAS MADE TO CONTAIN THE FRAGMENT BY STENTING OVER THE WIRE FRAGMENT. AGAIN UPON ATTEMPT TO REMOVE THE GUIDEWIRE, A WIRE FRAGMENT SHEARED OFF. A THIRD CARDIOLOGIST CANNULATED THE PATIENT AND DISCOVERED A MAJOR THROMBUS FROM THE LEFT MAIN CORONARY ARTERY, THE LEFT ANTERIOR DESCENDING AND OBTUSE MARGINAL ARTERY. THE CLINICAL CONDITION DETERIORATED TO A FATAL ARRHYTHMIA AND SUBSEQUENT DEATH. AUTOPSY DID NOT SHOW EVIDENCE OF VESSEL PERFORATION.