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Entrapment of a Transradial Coronary

Catheter

Asif Serajian, DO, Teja Gundala, MDFrom West Suburban Medical Center, Oak Park, Illinois.

S ince its introduction in the early ‘90s, transradial access (TRA) has progressively gained

worldwide acceptance and has replaced femoral access for percutaneous angi-ography and percutaneous coronary intervention (PCI) in some countries.1 Norway, Bulgaria, and Malaysia seem to be utilizing TRA the most (70% to 80%), while in United States it has been shown to be the chosen meth-od of PCI in less than 2% of cases.1,2 Transradial access, when compared to the traditional femoral approach, has been proven by strong retrospective and prospective data, in reducing access site complications, length of hospital stay, decline in expenses, and improve-ment in clinical outcomes.1,3 Stud-ies have also suggested that patients, who underwent both femoral and ra-dial approach, prefer the latter due to decreased discomfort.4 Despite these potential advantages, TRA has well-

documented complications such as radial artery occlusion, arterial spasm, nonoc-clusive radial artery injury, hand isch-emia, perforation, and pseudoaneurysm.3

As utilization of TRA for PCI has tremendously increased in recent years, there have been a few case reports highlighting a unique complication of a kinked and looped coronary cathe-ter in radial or axillary arteries. To our knowledge, the first report of catheter knotting and successful unknotting during TRA was described by Dr. Te-jas Patel in the May 2011 issue of The Journal of Invasive Cardiology.5

Following this, a few more case re-ports, from all over the world, were published in 2012 regarding this com-plication. Although these publications reported a very similar complication, each author described a distinct method of resolving this issue. Viable document-ed techniques of unraveling a kinked and entrapped catheter included the

(1) BP cuff technique, (2) femoral snare technique, (3) long sheath technique, and (4) balloon retrieval technique.5-9

As TRA becomes more ubiquitous, this unique complication will likely be encountered more frequently. We faced this exact complication in our cardiac catheterization lab in late 2011, which spurred our interest to explore this top-ic further. The purpose of this article is to discuss possible etiologies, potential methods of prevention and provide vi-able documented techniques of success-fully resolving this complication.

PLAUSIBLE ETIOLOGIESPlausible etiologies of kinking lead-

ing to immobilization include use of catheters made for femoral approach, tortuosity of vasculature, excessive torqueing and manipulation of the catheter, and even vasospasm.

Many of the coronary catheters used today for transradial approach are usu-

ABSTRACT: Transradial arterial access for percutaneous angiography and intervention has gained worldwide ac-ceptance in recent years. This method has demonstrated significant reductions in bleeding, access site compli-cations, length of hospital stay, decline in expenses, and improvement in clinical outcomes when compared to femoral and brachial approaches. Despite these potential advantages, transradial access has well-documented complications such as radial artery occlusion, arterial spasm, nonocclusive radial artery injury, hand ischemia, perforation, and pseudoaneurysm. Here, we explore a unique and emerging complication of a kinked and looped coronary catheter in radial or axillary arteries during transradial access for percutaneous procedures. Interven-tional cardiologists commonly face mild catheter kinking, but frank entrapment of a kinked catheter is a matter of concern. As transradial access becomes more ubiquitous, this unique complication will likely be encountered more frequently. Our goal is to discuss possible etiologies, potential methods of prevention and provide viable documented techniques of successfully resolving this complication.

VASCULAR DISEASE MANAGEMENT 2013;10(12):E249-E253Key words: access site management, interventional cardiology

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ally made for transfemoral access. As most operators today prefer the right radial artery (RRA), there is a need to rotate the pre-shaped catheter in an at-tempt to navigate across the S-shaped morphology of the right subclavian-innominate-aorta access.

This consequently prolongs proce-dure time and also leads to excessive manipulation of the catheter.11,12 Exces-sive manipulation combined with sig-nificant subclavian tortuosity results in increased resistance and loss of one-to-one torque. As a result, there is a higher chance of downstream looping and kinking.5 Further brute manipulation to relieve the loop in the brachial or radial arteries increases the probability of va-sospasm, likely due to significant mus-cular component along with alpha-1 receptors, resulting in entrapment.10,12

METHODS OF PREVENTIONPotential methods of prevention of

looping include using the left radial

artery (LRA) for TRA, refraining from rotating the catheter greater than 180°, maintaining a guidewire, and also careful monitoring the pressure trac-ings. Ninety percent of interventional cardiologists prefer RRA for TRA.12 While severe right subclavian tortu-osity is observed in 10% of patients undergoing TRA for coronary proce-dures, there is also a

double incidence of operator-reported moderate subclavian tortuosity with the RRA compared to LRA.11,13 Sub-clavian tortuosity is associated with in-creased catheter manipulation and pro-cedural time.11 Hence, using the LRA as the access site could potentially de-crease procedural time, unwarranted manipulation, decrease resistance, in-crease one-to-one torque, and likely reduce downstream looping.

Refraining from rotating the catheter greater than 180° prevents buildup of torque proximally that is not transmit-ted to the catheter tip.7 Hence, there is greater control of the distal catheter and decreased unforeseen catheter be-havior proximally, which could prevent looping and kinking. Close observa-tion of the pressure curve while torque-ing could also prevent looping. When there is partial dampening of the pres-sure curve, suggesting loss of advance-ment of the catheter, applying further torque could again result in unantici-

pated catheter behavior.7 Many opera-tors have also suggested maintaining a guidewire within the catheter to en-hance one-to-one torque if needed.5-9

METHODS OF RESOLUTIONViable documented techniques of

unraveling a kinked catheter include the BP cuff technique, femoral snare tech-nique, long sheath technique and bal-loon retrieval technique. The following techniques are mentioned in chrono-logical order of their published dates in various scholarly journals.

BP Cuff Technique To our knowledge, Tejas Patel et

al described the first report of cath-eter knotting and successful unknotting during TRA in 2011 in The Journal of Invasive Cardiology.5 This case highlights a simple, yet effective, technique of un-knotting a coronary catheter trapped within the radial artery using a routine sphygmomanometer.

While engaging the right coronary artery via right TRA, authors noted difficulty in advancement of the cath-eter tip. There was dampening of the pressure tracings along with difficulty injecting contrast media. Fluoroscopic investigation revealed a tight knot of the 5 Fr Tig catheter (Terumo Cor-poration) in the right radial artery. Initial gentle counterclockwise ma-nipulations along with introduction of a standard 0.035˝ guidewire were unsuccessful. External fixation of the distal end of the catheter manually in the brachial region was also fruitless due to significant adipose tissue. Fi-nally, a BP cuff was fixed in the bra-chial region, distal to the knot, and inflated to 200 mmHg while the cath-

Figure 1. Tight knot of the 5 Fr Tig catheter in the right radial artery (A). Blood pressure cuff fixed in the brachial region, distal to the knot, inflated to 200 mmHg.

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eter was rotated in the counterclock-wise direction proximally (Figure 1). This maneuver unraveled the knot and allowed free movement.

Femoral Snare TechniqueIn January of 2012, two more case

reports regarding catheter entrapment during TRA were published from two different parts of the world. One was by Khoubyari et al from The Univer-sity of Arizona7 and the other by Kim et al from The Catholic University of Korea in Suwon, South Korea.6 Inter-estingly, both of the authors employed a snare via the right femoral artery to resolve this complication.

Khoubyari et al describe a case of catheter entrapment and kinking in the radial artery, which was successfully re-moved by using a gooseneck snare via the transfemoral route.7 During right TRA, authors describe difficulty in en-gaging the RCA necessitating multiple attempts of manipulating the catheter to gain access. Fluoroscopic investiga-tions revealed a 360° kinked 5 Fr JR5 (Cordis Corporation) catheter within the radial artery. Insertion of a standard guidewire along with antispasmodic medication cocktail was unsuccessful. To resolve this complication, a 7 Fr EN Snare (Merit Medical) catheter was introduced through a 7 Fr sheath via the right common femoral artery. The 7 Fr EN Snare catheter was advanced into the aortic arch and the distal end of the 5 Fr JR5 was captured (Figure 2). While simultaneously manipulating the catheters in opposite directions, the JR5 catheter dislodged from the right radial artery and successfully retrieved through its radial sheath.

Kim et al also described a case where

a kinked and en-trapped catheter in the right radial ar-tery during TRA was removed using a GooseNeck snare (Covidien).6 During right TRA, authors describe much dif-ficulty engaging the coronary ostium due to significant innominate tortu-osity. After several attempts of manipu-lating the 4 Fr cath-eter, it was noted to be kinked within the small right radial artery. Attempts to unravel the catheter caused significant pain to the patient. To resolve this com-plication, authors employed an 8 Fr JL4 guiding catheter via the right femo-ral artery and pulled the entrapped 4 Fr catheter into the descending aorta from the ostium. A 6 Fr Amplatz GooseNeck Snare Kit (Covidien) was introduced via the 8-Fr guiding catheter and the distal tip of the entrapped 4 Fr catheter was con-trolled and pulled up into the brachial artery (Figure 3). Using a 0.035˝ J wire (Abbott Vascular) the kinked 4 Fr cath-eter was unraveled and safely removed through the right radial artery.

Long Sheath Technique In September of 2012, Waked et al

described an approach of resolving a kinked catheter within the brachial artery using a 5 Fr long sheath.8 The authors did not describe whether they attempted this on the right or the left

Figure 2. Kinked 5 Fr JR5 catheter within the radial artery (A). 7 Fr EN Snare catheter advanced into the aortic arch to capture the distal end of the JR5 (B).

Figure 3. 4 Fr catheter kinked within the radial artery (A). A 6 Fr Amplatz GooseNeck Snare Kit was introduced via the 8 Fr guiding catheter (B).

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CLINICAL REVIEW

upper extremity. While manipulating a 5 Fr JL4 (Cordis

Corporation) through a 6 Fr sheath to engage the left coronary artery, authors noted loss of catheter advancement due to spasm. Fluoroscopy revealed a kinked catheter within the brachial segment. Initial gentle maneuvers to unravel the catheter were unsuccessful. To resolve the issue, the proximal end of the JL4 was cut and the 6 Fr 12 cm sheath was

exchanged with a 5 Fr long sheath while the trapped JL4 acted as a guidewire. Under fluo-roscopy, the long 5 Fr sheath was advanced to the anticubital fossa (Figure 4) to the base of the kink, and the trapped JL4 was gently pulled back, unraveling the kink, and slipped back in the sheath.

Balloon Retrieval Technique In September of

2012, Layland et al pub-lished a unique method of rescuing a kinked coronary catheter in the axillary artery dur-ing coronary catheter-ization via TRA.9 This case is different from the others not only in terms of the method, but also in that the kinking occurred in the larger axillary artery upon removal, not ad-vancement of the cath-eter.

During left TRA, af-ter successfully treating occlusive coro-nary disease, authors note kinking of an EBU 3.5 guiding catheter (Medtronic) within the axillary region upon retriev-al. Gentle catheter manipulation, rota-tion, use of a standard 0.035˝ guidewire, and a super-stiff wire were unsuccess-ful. To resolve the problem, a 6 Fr JR4 was used to gain access to the kinked catheter via femoral approach. The JR4 was advanced close to the distal tip of

the kinked EBU guiding catheter, and a Whisper MS wire (Abbott Vascular) was advanced through the JR4 and into the kinked EBU. Next a 3.0 mm x 15 mm NC balloon (Abbott Vascular) was passed through the JR4 over the MS wire and was inflated within the distal end of the kinked EBU catheter (Figure 5). With gentle backward traction, the JR4 and the EBU were retrieved into the ascending aorta and the kink was unraveled using the JR4/balloon appa-ratus allowing the EBU catheter to be removed through the radial access.

DISCUSSIONSince its introduction, TRA has

gained worldwide acceptance. As TRA becomes more commonplace, com-plications related to this procedure, including the unique issue of kinked coronary catheter, will likely be en-countered more frequently. Our goals are to shed light upon this emerging complication and discuss possible eti-ologies, discuss potential methods of prevention, and provide viable docu-mented techniques of successfully re-solving this complication.

We believe if a coronary catheter were to become kinked and immobi-lized during TRA, it would be logical to first attempt noninvasive maneu-vers of inflating a BP cuff distal to the kink and gently manipulating the proximal catheter to unravel the kink. If this does not resolve the complica-tion, depending on the proximity of the kink from the access site, one can attempt to dislodge the kink using a long sheath as described above. If this were also unsuccessful, one could at-tempt more invasive methods such as the femoral snare technique or the

Figure 4. By advancing the long 5 Fr sheath (blue) to the base of the kink, the trapped JL4 (black) can be gently pulled back to unravel the knot.

Figure 5. JR4 (blue) advanced close to the distal tip of the kinked EBU guiding catheter (black) and a Whisper MS wire (yel-low) advaned through the JR4 and into the kinked EBU.

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balloon retrieval technique. Amongst these, depending on the situation, we prefer the balloon retrieval technique as one can avoid inserting a large-caliber femoral sheath and also have true control of both catheters at all times. Perhaps if all else fails, it would be wise to have a vascular surgeon in the cardiac catheterization lab as one proceeds further.

Editor’s Note: Disclosure: The au-thors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures in relation to the content of this manuscript.

Manuscript received June 25, 2013; provisional acceptance given July 10, 2013; manuscript accepted August 1, 2013.

Address for correspondence: Asif Serajian, DO, 183 N. Addison Ave., Ste. 170, El-mhurst, IL 60126, United States. Email: aserajian1@gmail.com n

REFERENCES 1. Caputo RP, Tremmel JA, Rao S, et al.

Transradial arterial access for coronary and

peripheral procedures: executive summary

by the trans radial committee of the SCAI.

Catheter Cardiovasc Interv. 2011;78(6):823-

839.

2. Rao SV, Ou FS, Wang TY, et al. Trends

in the prevalence and outcomes of radial

and femoral approaches to percutaneous

coronary intervention: A report from the

National Cardiovascular Data Registry.

JACC Cardiovasc Interv. 2008;1(4):379-386.

3. Kanei Y, Kwan T, Nakra NC, et al. Tran-

sradial cardiac catheterization: a review of

access site complications. Catheter Cardiovasc

Interv. 2011;78(6):840-846.

4. Cooper CJ, El-Shiekh RA, Cohen DJ, et

al. Effect of transradial access on quality

of life and cost of cardiac catheterization:

A randomized comparison. Am Heart J.

1999;138(3 Pt 1):430-436.

5. Patel T, Shah S, Pancholy S. A simple ap-

proach for the reduction of knotted coro-

nary catheter in the radial artery during

the transradial approach. J Invasive Cardiol.

2011;23(5):E126-E127.

6. Kim JY, Moon KW, Yoo KD. Entrapment of

a kinked catheter in the radial artery during

transradial coronary angiography. J Invasive

Cardiol. 2012;24(1):E3-E4.

7. Khoubyari R, Arsanjani R, Habibzadeh

MR, Echeverri J, Movahed MR. Success-

ful removal of an entrapped and kinked

catheter during right transradial cardiac

catheterization by snaring and unwinding

the catheter via femoral access. Cardiovasc

Revasc Med. 2012;13(3):202.E1-E3.

8. Waked A, Khoueiry G, Bhat T. Entrap-

ment of a looped/kinked catheter in the

brachial artery and its successful retrieval

during transradial coronary catheterization.

J Invasive Cardiol. 2012;24(9):471-472.

9. Layland J, McGeoch R, Sood A. Novel

method of rescuing kinked guide catheter

from axillary artery in transradial coronary

intervention: the balloon retrieval tech-

nique. J Invasive Cardiol. 2012;24(9):E205-

E206.

10. Kallivalappil SC, Pullani AJ, Abraham B,

Kumar MK, Ashraf SM. Entrapment of a

transradial angiogram catheter because of

severe vasospasm. J Cardiothorac Vasc Anesth.

2008 Jun;22(3):428-430.

11. Sciahbasi A, Romagnoli E, Burzotta F, et

al. Transradial approach (left vs right) and

procedural times during percutaneous

coronary procedures: TALENT study. Am

Heart J. 2011;161(1):172-179.

12. Pullakhandam NS, Yang ZJ, Thomas S,

Wasenko J. Unusual complication of

transradial catheterization. Anesth Analg.

2006;103(3):794-795.

13. Bertrand OF, Rao SV, Pancholy S, et al.

Transradialapproach for coronary angiog-

raphy and interventions: Results of the first

international transradial practice survey.

JACC Cardiovasc Interv. 2010;3(10):1022-

1031.

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