A Novel Retrograde Bailout Technique to Unkink an Entrapped Catheter During Transradial Cardiac Catheterization
Akarsh Parekh, MD, Ascension Macomb-Oakland Hospital, Warren Campus, Mount Clemens, MI
Akarsh Parekh, MD, Ascension Macomb-Oakland Hospital, Warren Campus, Mount Clemens, MI, Jay Mohan, D.O., FSCAI, McLaren Cardiovascular Institute, Troy, MI and Sibin K. Zacharias, M.D., McLaren Macomb, Mt. Clemens, MI
Title
A Novel Retrograde Bailout Technique to Unkink an Entrapped Catheter During Transradial Cardiac Catheterization
Introduction
Compared to transfemoral access, transradial access is associated with reduced access site complication, shorter length of stay, and improved cost effectiveness. However, due to anatomical variations and subclavian tortuosity, catheter manipulation via a transradial approach can be challenging. One complication that has been reported in the literature is kinking of the catheter, which can be painful, cause serious vascular consequences, and be life-threatening. To date there are multiple percutaneous maneuvers that can be used to unkink a catheter, using an antegrade approach. However, when these maneuvers fail, surgery is the patients only remaining option. We propose an alternative retrograde approach to unkink a catheter.
Clinical Case
A 74 year old female with a past medical history of severe aortic stenosis, hypertension, transient ischemic attack, and diabetes, presented to our hospital for an outpatient invasive evaluation prior to aortic valve replacement. For her invasive coronary angiography, a 6 French sheath was placed into right radial artery. Intraarterial anti-spasm medications: verapamil and nitroglycerin were administered. A 5 French Tiger (TIG) 4.0 diagnostic catheter was attempted to engage into the left coronary artery ostium, the catheter was over-rotated leading it to be kinked in the right subclavian artery at two different locations. After failed antegrade unkinking bail out techniques, we decided to use a novel retrograde balloon technique to attempt to unkink the entrapped catheter. A 6 French sheath was inserted into the right femoral artery and a 6 French Judkin’s right (JR) 4.0 guide catheter was advanced to the right subclavian artery and positioned adjacent to the distal end of the kinked TIG catheter. A 0.014 in Prowater wire was advanced from the transfemoral JR catheter and into the distal lumen of the kinked TIG catheter. A 3.0 x 22 mm non-compliant balloon was railed over the Prowater wire and placed in the distal lumen of the TIG catheter. The balloon was inflated to 12 atmospheres within the TIG catheter which was then pulled across the brachiocephalic artery and then into the descending aorta. The TIG catheter was then pulled from both ends successfully relieving both kinked segments. The TIG catheter was then pulled out of the patient’s body from the original TR approach. The patient then underwent successful diagnostic cardiac catheterization without further complications.
Discussion
TR cardiac catheterization continues to be an increasingly utilized approach. For the most part it is associated with lower rates of major complications when compared to transfemoral approach, however it does have various nuances that the operator has to be familiar with. When using the TR access site, the catheter has to be rotated to operate around the S shaped contour of the right subclavian and innominate artery. Usually kinked catheter complications can be managed by conservative attempts; however, when none of the aforementioned methods work, forceps or snares can be used. To our knowledge there have been no other reported cases of a retrograde balloon technique to unkink a catheter.