Abstract
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, nonocclusive radial artery injury, vasospasm, and compartment syndrome. Herein, we present an unusual case of entrapment and kinking of a catheter in the radial artery, which was successfully removed by using a gooseneck snare via the transfemoral route. The distal and proximal tips were then simultaneously rotated in opposite directions, allowing for the unkinking and removal of the catheter. To our knowledge, this is the first report of this rare complication.
1
Background
Lucien Campeau initially described the use of radial access for diagnostic coronary angiography in 1989 . Subsequently, Ferdinand Kiemeneij and Gert Jan Laarman reported successful transradial approach for coronary artery stenting in 1993 . Ever since its introduction, the transradial approach for cardiac catheterization has significantly evolved. This approach has gained significant popularity and has increasingly been utilized as the preferred access site throughout the world due to lower access site complications , cost-effectiveness , and shorter hospital course , despite its lower overall success rate . In spite of its overall lower complication rates compared to the transfemoral approach, the transradial approach has its own inherent complications. These rare, but known, complications of transradial approach include radial artery occlusion , thrombosis , nonocclusive radial artery injury , catheter entrapment , resistant vasospasm , compartment syndrome, pseudoaneurysm, and arteriovenous fistula . To the best of our knowledge, entrapment of a kinked and looped catheter in the radial artery has not been previously reported or described. In this report, we present a case of a catheter entrapment and kinking in the radial artery, which was successfully removed by using a gooseneck snare via the transfemoral route.
2
Case report
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 micropuncture kit (Cook Medical Inc., Bloomington, IN, USA), and a 5-Fr sheath (Cordis Corporation, Bridgewater, NJ, USA) was successfully placed in the right radial artery. A cocktail of unfractionated heparin (5000 U), verapamil (500 µg), and nitroglycerin (400 µg) was administered following the sheath insertion. A 5-Fr JR5 catheter (Cordis Corporation, Bridgewater, NJ, USA) was easily advanced into the aortic root. However, we had great difficulty engaging the right coronary artery. During repeated attempts, 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° kinked loop in the catheter ( Fig. 1 ). 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 antispasm medications. The decision was made to obtain femoral access with the goal of snaring and removing the catheter. Utilizing a modified Seldinger’s technique, a 7-Fr sheath (Cordis Corporation, Bridgewater, NJ, USA) was placed into the right common femoral artery. A 7-Fr EN Snare catheter (Merit Medical Systems, South Jordan, UT, USA) was advanced into the aortic arch and was used to capture the distal end of the JR5 ( Figs. 2 and 3 ). Subsequently, by gently pulling and rotating the distal end of the JR5 with the EN Snare catheter, while simultaneously rotating and pulling the hub of the JR5 catheter in the opposite direction, we were able to unkink and remove the catheter through the radial sheath ( Figs. 4 and 5 ). At this point, from the femoral artery, a 5-Fr Kumpe catheter (Cook Medical Inc., Bloomington, IN, USA) 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-Fr 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.
2
Case report
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 micropuncture kit (Cook Medical Inc., Bloomington, IN, USA), and a 5-Fr sheath (Cordis Corporation, Bridgewater, NJ, USA) was successfully placed in the right radial artery. A cocktail of unfractionated heparin (5000 U), verapamil (500 µg), and nitroglycerin (400 µg) was administered following the sheath insertion. A 5-Fr JR5 catheter (Cordis Corporation, Bridgewater, NJ, USA) was easily advanced into the aortic root. However, we had great difficulty engaging the right coronary artery. During repeated attempts, 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° kinked loop in the catheter ( Fig. 1 ). 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 antispasm medications. The decision was made to obtain femoral access with the goal of snaring and removing the catheter. Utilizing a modified Seldinger’s technique, a 7-Fr sheath (Cordis Corporation, Bridgewater, NJ, USA) was placed into the right common femoral artery. A 7-Fr EN Snare catheter (Merit Medical Systems, South Jordan, UT, USA) was advanced into the aortic arch and was used to capture the distal end of the JR5 ( Figs. 2 and 3 ). Subsequently, by gently pulling and rotating the distal end of the JR5 with the EN Snare catheter, while simultaneously rotating and pulling the hub of the JR5 catheter in the opposite direction, we were able to unkink and remove the catheter through the radial sheath ( Figs. 4 and 5 ). At this point, from the femoral artery, a 5-Fr Kumpe catheter (Cook Medical Inc., Bloomington, IN, USA) 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-Fr 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.
