Abstract
Severe radial artery spasm is a complication of transradial cardiac catheterization. We describe a case of severe radial artery spasm causing catheter entrapment. The spasm was refractory and resistant to intra-arterial vasodilators, systemic vasodilators, and moderate sedation. Rotaglide™ (Boston Scientific, Marlborough, MA) solution via continuous infusion was delivered through the catheter and then the sheath, resolving the spasm and allowing the removal of the catheter and sheath without injury to the radial artery.
Highlights
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Transadial access for coronary catheterization is complicated by radial artery spasm in 5–15% of cases
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Radial artery spasm can be managed stepwise with analgesia and sedation, spasmolytics, general anesthesia and vascular surgery
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In this case of catheter entrapment, general anesthesia and vascular surgery consultation were avoided by employment of Rotaglide™ infusion
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Rotaglide™ infusion can be useful in refractory cases of catheter entrapment
1
Introduction
Transradial access (TRA) for diagnostic and interventional coronary catheterization has become a well-established approach technique, first introduced in 1989 [ ]. Randomized trials have demonstrated advantages compared to the transfemoral approach (TFA) in both diagnostic and therapeutic cardiac catheterizations in terms of decreased bleeding and vascular complications with similar rates of procedural success [ , ]. Additionally, patients prefer TRA due to less overall discomfort, earlier ambulation, and earlier discharge from the hospital [ ]. However, the acceptance of TRA to be the preferred and routine approach for cardiac catheterization in the United States is still limited with usage rates below 50% [ ]. Reasons for limited national use include increased operator learning curve with more catheter manipulation that can increase radiation dose, radial artery caliber limiting the size of guide catheter insertion, and radial artery injury and occlusion [ ]. To our knowledge, this is the first published case of severe radial artery vasospasm that required Rotaglide™ (Boston Scientific, Marlborough, MA) solution to successfully resolve vasospasm in addition to the standard treatment with spasmolytics.
2
Case presentation
A 52-year-old man with a medical history of post-traumatic stress disorder, depression, and chronic tobacco abuse presented to our hospital for elective cardiac catheterization. The patient complained of intermittent chest pain for one to two months prior to presentation. He underwent a pharmacologic stress test that revealed no definite ischemia; however, the patient’s chest pain continued and a cardiac catheterization was scheduled. On pre-procedure physical examination, bilateral radial pulses were equal and 2+. He was 5 ft 9 in. tall with a body mass index (BMI) of 29 kg/m 2 . In the catheterization laboratory, right radial artery approach was chosen and he was prepped and draped in the usual sterile fashion. He was given moderate sedation with midazolam and fentanyl prior to initiating the procedure. The right radial artery was accessed with a Glidesheath Slender 6 French (Terumo Medical Corporation, Tokyo, Japan) without difficulty. Verapamil was given intra-arterially as our standard spasmolytic. Initial Jacky 5 French catheter (Terumo Medical Corporation, Tokyo, Japan) advancement proceeded without resistance into the aortic root. However, while manipulating the catheter in attempt to engage the right coronary artery, the patient complained of severe right arm pain with a concomitant vagal reaction. After adequate resuscitation, the catheter was unable to be removed distal to the right axillary artery therefore peripheral angiography was performed. Angiography revealed that the catheter was in an auxiliary radial artery coming off a high bifurcation of the brachial artery close to the level of the humeral head ( Fig. 1 ). After infusion of nitroglycerin bolus through the catheter with additional verapamil through the glidesheath, the catheter was still entrapped in the axillary artery. More sedation and warm compresses on the arm were administered and the case was converted to a transfemoral approach. Coronary angiography was completed via a right femoral artery approach without any complications and the patient was found to have non-obstructive coronary artery disease. Despite several doses of verapamil and nitroglycerin and midazolam and fentanyl, the radial artery catheter was still unable to be manipulated. Therefore, at this time it was decided to infuse Rotaglide™ (Boston Scientific) solution. Twenty milliliters (mL) were diluted in 1000 mL normal saline and a slow infusion was initiated through the catheter. After 5 min of infusion, the catheter was successfully removed. After removal of catheters, repeat peripheral angiography was performed which revealed no upper extremity arterial perforation and spasm resolution. After catheter removal, the patient had no further discomfort. The infusion was continued through the glidesheath, which also allowed the glidesheath to be removed.
