Successful Removal of Entrapped and Kinked Catheter during Right Transradial Cardiac Catheterization by Snaring and Unwinding the Catheter via Femoral Access M Reza Movahed, MD, PhD, FACP, FACC, FSCAI CareMore Regional Cardiology Director of Arizona Professor of Medicine University of Arizona Sarver Heart Center Tucson, Az

Back ground: Since its introduction by Campeau in 1989, the transradial approach for coronary angiography has gained significant popularity among interventional cardiologists due to its lower access site complication rates, cost-effectiveness, and shorter hospital course. Although, the transradial approach is much safer than the transfemoral approach, it has its own inherent rare complications including radial artery occlusion, thrombosis, non-occlusive radial artery injury, vasospasm, and compartment syndrome. Herein, we present an unusual case of catheter entrapment and kinking in the radial artery with detail description to how to resolve this problem

Case A 74-year-old male with past medical history significant for diabetes mellitus, hypertension, and hyperlipidemia had been referred for coronary angiography due to exertional chest pain and an abnormal myocardial perfusion imaging. Based on patient and operator preference, and a negative modified Allen’s test, a decision was made to proceed via a transradial approach. Right radial access was obtained using a micro-puncture kit and a 5-French sheath was successfully placed in the right radial artery. A-cocktail of unfractionated heparin (5000 Units), Verapamil (500 mcg), and nitroglycerin (400 mcg) was administered following the sheath insertion.

Case A 5-French JR4 catheter was easily advanced into the aortic root. However, we had great difficulty engaging the right coronary artery. During repeated attempts by “fellows”, there was a sudden loss of aortic pressure tracing, and attempts at aspirating blood through the catheter lumen were unsuccessful. Fluoroscopy of the right forearm demonstrated a 360-degree kinked loop in the catheter

What to do now?

Case Multiple attempts at advancing a wire (0.035” J-wire and an angled tip glide wire) through the catheter lumen in hopes of unkinking the catheter failed. In addition, we were unable to advance, withdraw, or manipulate the catheter despite administering multiple anti-spasm medications.

CaSE The decision was made to obtain femoral access with the goal of snaring and removing the catheter. Utilizing modified Seldinger’s technique, a 7-French sheath was placed into the right common femoral artery. A 7-French EN Snare catheter was advanced into the aortic arch and was used to capture the distal end of the JR4

cASE Subsequently, by gently pulling and rotating the distal end of the JR4 with the EN Snare catheter, while simultaneously rotating and pulling the hub of the JR4 catheter in the opposite direction, we were able to unkink and remove the catheter through the radial sheath

Case At this point, from the femoral artery a 5-French Kumpe catheter was advanced over a 0.035” wire into the right subclavian artery and a selective right upper extremity angiogram with distal run-off was performed, which demonstrated no vascular complication. Finally, selective coronary angiography was performed using 6-French JL4 and JR4 catheters via the right femoral artery which showed multi-vessel coronary disease including the left main. He was then referred for coronary bypass surgery.

How could be prevent it? a) Keep the rule of rotation not to exceed 180 degrees (even more important with 4F catheters), b) Keep a wire within the catheter to enhance the torque if needed, c) Always watch your pressure while torquing and when pressure curve is partially reduced, untorque.

Questions?