Transcript Successful coronary angiography with adequate image

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 multivessel 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?