Snare The Knots: Retrieval of Radial Guide Catheter in a Case of Left Aortic Arch with Aberrant Right Subclavian Artery
Chinmaya Mareddy, M.D., Augusta University Medical Center, Augusta, GA
Chinmaya Mareddy, M.D., Augusta University Medical Center, Augusta, GA
Title Snare The Knots – Retrieval Of Radial Guide Catheter In A Case Of Left Aortic Arch (LAA) With Aberrant Right Subclavian Artery (ARSA) Introduction Knot formation of a kinked radial guide catheter is a frightening complication associated with radial approach and prevalence increases in the setting of aortic arch anomalies. This case highlights strategies to remedy guide catheter complications and avert surgical intervention. Clinical Case 59-year-old obese male with hypertension, dyslipidemia and benign physical exam admitted for crescendo angina culminating in NSTEMI. EKG showed inferior Q waves. Troponin was elevated. TTE showed overall preserved EF with subtle inferior wall hypokinesis. Coronary angiography via right radial approach revealed 99% mid RCA stenosis. PCI was attempted and the lesion was crossed; however, attempt to advance IVUS catheter resulted in guide catheter backing out. Fluoroscopic exam revealed a kinked guide catheter. Right subclavian artery appeared tortuous and anomalous. Attempts to retrieve this kinked catheter resulted in marked knot formation. Discussion Initial anterograde attempts to retrieve the kinked catheter with multiple guidewires (0.014 and 0.035) using both front and back ends were unsuccessful and resulted in worsening of knot formation. Subsequently, a 6F JR-4 guide was advanced to the aorta via femoral approach and ostium of the aberrant right subclavian artery was located on the left aortic arch. The right subclavian artery was cannulated and retrograde attempts to snare (9x15 Merit Medical En Snare) were unsuccessful. Next, a 5x40 mm balloon was inflated in the axillary artery to trap the tip of the catheter; however, this too was unsuccessful. Finally, reattempt with En Snare was successful to trap the tip of the knotted catheter. With firm fixation, torque on the guide catheter was relieved with counter rotation. The catheter was successfully removed and angiogram of the axillary artery was normal. Brisk radial flow was noted. Then, RCA lesion was successfully treated with PTCA/DES.