ABSTRACT: The transradial approach is currently popular for vascular access during percutaneous coronary angiography and intervention. Catheter kinking during catheter manipulation is not uncommon, but mostly the kinked catheter can be unraveled by gentle rotation of catheter in the opposite direction. We describe a case in which the diagnostic catheter was kinked and entrapped in the small radial artery during transradial angiography. Attempts to withdraw or to unravel the catheter with gentle rotation were unsuccessful. We were able to catch the catheter tip with a 6 Fr Amplatz gooseneck snare kit (ev3, Inc.) guided by an 8 Fr guiding catheter via right femoral approach. We pulled the kinked catheter up into the brachial artery with large diameter where successful unraveling was possible, allowing for its successful removal through the radial sheath.
J INVASIVE CARDIOL 2012;24(1):E3-E4
Key words: complications; catheterization; retrieval; transradial
Case Report. A 58-year-old man presented with unstable angina. Retrograde radial angiogram showed small radial artery and dominant ulnar artery (Figure 1A). Transradial coronary angiogram was attempted with a 4 Fr diagnostic catheter, but it was hard to engage the coronary ostium because of excessive tortuosity of the innominate artery (Figure 1B). After several attempts, the catheter was kinked and entrapped in the radial artery (Figure 1C). The catheter could not advance into the brachial artery and could not be withdrawn from the radial artery. Attempts to unravel the catheter with gentle rotation caused severe forearm pain. After femoral artery puncture, anterograde brachial angiogram confirmed the position of entrapped catheter within the radial artery (Figure 1D). Transfemoral coronary angiogram showed severe stenosis involving the left anterior descending artery (LAD). To avoid possible injury of aortic valve or coronary ostium during manipulation of the retrieval device, the entrapped catheter was pulled down into descending aorta using 8 Fr JL4 guiding catheter. The kinked catheter tip was caught using a 6 Fr Amplatz GooseNeck Snare Kit (ev3, Inc.) guided by an 8 Fr guiding catheter via a right femoral approach (Figure 2A). While gently pulling down the snare kit, the entrapped catheter was pulled up into the brachial artery (Figures 2B and 2C). After releasing the snare (Figure 2D), the kinked catheter was unraveled with a .35 inch J-wire and successfully removed through the radial sheath. After removal, percutaneous coronary intervention of the LAD was performed successfully using 2 stents (Figures 3A and 3B). The patient had an uneventful recovery and was discharged on the following day.
Discussion. The transradial approach is currently popular for vascular access during percutaneous coronary angiography and intervention. Most interventional cardiologists are familiar with doing the procedure at the right side of the patient since the right radial approach is more convenient for manipulating the devices, including the guide catheter. Therefore, almost 90% of interventional cardiologists select the right radial artery as a first access route when performing transradial procedures in international survey data.1 Severe tortuosity of the right subclavian artery is known to be present in approximately 10% of patients performing transradial angiography.2 It may cause discomfort associated with prolonged manipulation of catheters, access failure, incomplete examination, arterial dissection, and arterial perforation with mediastinal and retropharyngeal hemorrhage during catheterization through the right arm vessel. But, the overall incidence of crossover due to severe tortuosity of radial, brachial, and subclavian artery is rare (less than 1%) in several studies.2–4
Catheter kinking during catheter manipulation is not uncommon, but usually the kinked catheter can be unraveled by gentle rotation in the opposite direction. In our case, the kinked catheter was entrapped in the small radial artery during transradial angiography. We were able to catch the catheter tip with a snare and pull the kinked catheter up into the brachial artery with large diameter where successful unraveling is possible, allowing for its successful removal through the radial sheath. This saved the patient from unplanned surgery. Removal of the kinked catheter or foreign bodies5,6 using the GooseNeck snare is a safe and easily applied procedure.
- Bertrand OF, Rao SV, Pancholy S, et al. Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey. JACC Cardiovasc Interv. 2010;3(10):1022-1031.
- Cha KS, Kim MH, Kim HJ. Prevalence and clinical predictors of severe tortuosity of right subclavian artery in patients undergoing transradial coronary angiography. Am J Cardiol. 2003;92(10):1220-1222.
- Kim JY, Yoon J. Transradial approach as a default route in coronary artery interventions. Korean Circ J. 2011;41(1):1-8.
- Yoo BS, Yoon J, Ko JY, et al. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol. 2005;101(3):421-427.
- Rodrigues D, Sá e Melo A, da Silva AM, Carvalheiro V, Manuel O. Percutaneous retrieval of foreign bodies from the cardiovascular system. Rev Port Cardiol. 2007;26(7-8):755-758.
- Yedlicka JW Jr, Carlson JE, Hunter DW, Castañeda-Zúñiga WR, Amplatz K. Nitinol gooseneck snare for removal of foreign bodies: experimental study and clinical evaluation. Radiology. 1991;178(3):691-693.
From the Department of Internal Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Suwon, South Korea.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted April 29, 2011, provisional acceptance given June 3, 2011, final version accepted June 27, 2011.
Address for correspondence: Keon-Woong Moon, MD, PhD, Department of Internal Medicine, St. Vincent’s Hospital, #93-6, Ji-dong, Paldal-ku, Suwon, Gyunggi-do, 442-723, South Korea. Email: firstname.lastname@example.org