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Kinked Catheter Unravelment in the Right Upper Extremity: An Unconventional Solution
Editor's Note: Figure 3 was incorrectly omitted from the print version of this article and is included below. Cath Lab Digest apologizes for the error.
Read a commentary from Dr. Morton Kern here.
According to the American College of Cardiology’s National Data Registry, use of the radial approach in cardiac catheterization has grown from 1% in 2008 to approximately 50% in the United States, with the right radial approach (RRA) being preferred. Historically, operators have worked on the right side of the patient, which has driven this approach. One of the most common issues with the RRA, arising in approximately 25% of patients1, is right subclavian tortuosity, which frequently hinders a straight route into the ascending aorta (AA). The right subclavian artery arises from the brachiocephalic trunk, with the presence of two consecutive vascular bifurcations at that level. Tortuosity may affect smooth access into the AA, which directly correlates with increased procedural time, operator radiation exposure, fluoroscopic time, dose area product (DAP), and contrast volume.2-4 Subclavian and innominate anatomical challenges have been previously described and are divided into five subsets: tortuosity, loop, stenosis, congenital aberrancy, and combined challenges.5 One of the byproducts from right subclavian tortuosity is kinking or knotting of the catheter from increased manipulation. Operators (especially those in training) frequently over-torque catheters in an attempt to achieve selective coronary engagement.
Case Presentation
A 93-year-old male who had been following with cardiology for worsening shortness of breath arrived in our cath lab. He had a history of chronic obstructive pulmonary disease, peripheral vascular disease (PVD), type 2 diabetes, hyperlipidemia, and hypertension. He was seen in the cardiology clinic, as he was only able to walk half a city block before getting short of breath. Additionally, he had been experiencing worsening lower extremity edema, but no chest pain at any time. He was sent for an echocardiogram that demonstrated an aortic valve area of 0.75cm2, peak velocity of 4.0 m/s, and a mean gradient of 37 mmHg with a left ventricular ejection fraction of 56-60%. He was worked up for transcatheter aortic valve replacement (TAVR) and as part of the workup, was sent for a coronary angiogram that revealed hemodynamically insignificant coronary artery disease.
Technique
The patient was extremely jovial upon entering the room and joked with staff, establishing an immediate rapport.
After access into the RRA, a 5 French Tiger Catheter (Terumo) was passed into the AA with moderate ease; however, the catheter crossed the trachea under fluoroscopy, noted immediately. This offered an indication of tortuosity aside from underlying clinical factors (age +65, hypertensive, short stature). Prior to engaging the coronaries, with the catheter sitting just at the sinotubular junction, we took a quick “flouro store” of the tortuosity in left anterior oblique/caudal views in order to adequately delineate the tortuosity and document it for any subsequent catheterizations. We found a tight subclavian loop (Figure 1) that proved to be problematic for the procedure. After several minutes of catheter manipulation, no further torque was being transmitted to the tip of the catheter and contrast was unable to be injected, with an altered aortic pressure waveform. We scanned the catheter through the upper vasculature and found the catheter was kinked in the distal right subclavian. A standard J-wire was introduced into the catheter to attempt to straighten the kink, to no avail. After further manipulation trying to unravel the kink, it moved into the mid brachial artery (Figure 2A-B). A hydrophilic Glidewire (Terumo) was then utilized, with the same results. We thought a possible solution would be to obtain femoral access, snare the catheter from the distal tip, and unravel the catheter; however, with the patient being pre-TAVR with PVD, we sought to avoid femoral access unless all other options were exhausted. We also postulated the use of this technique from the left radial, but with the degree of tortuosity and the tip of the catheter sitting distally in the right subclavian, the attending physician thought it would be a monumental feat.
After further consultation with the attending, we decided to use an unorthodox technique to untangle the catheter. With the kinked catheter sitting in the mid brachial artery, the technologist would apply pressure to the brachial artery proximal to the kinked catheter and simultaneously have the attending physician un-torque the catheter to straighten it.
We felt that due to the patient’s body habitus and palpable arteries, there was a good chance of success. The team’s extensive knowledge of vascular anatomy played a large role in this decision. We knew the brachial artery to be palpable on the anterior aspect of the elbow, and medially/inferiorly to the bicep tendon. The patient also had poor muscle tone, which helped in applying more direct pressure to the brachial artery, rather than muscle.
Unfortunately, the technologist would need to be close to the radiation source in order to help the patient, as well as have both hands in the primary radiation beam. After convening, we decided to attempt this technique with the use of minimal intermittent fluoroscopy and proper radiation protection. Regrettably, we did not have lead gloves available (which may or may not help with shielding, being in the primary beam). Under fluoroscopy, the kink was moved to the distal brachial artery very carefully while confirming the patient did not have pain in the arm. Once the catheter reached the distal brachial artery, under fluoroscopy, the technologist compressed the brachial artery with significant pressure proximal to the kink (Figures 3-4). The attending physician un-torqued and simultaneously pulled the catheter (Figure 5). Within seconds, we resolved the issue safely and efficiently. We aborted the RRA access site, cannulated the left distal radial artery (Figure 6), and completed the case.
Conclusion
Radiation is cumulative and as such, should be treated with the utmost precautions. This technique should not be routine practice in the cath lab. Although it worked well for our patient, cath lab operators and staff should be extremely hesitant to use this technique. It was used in our case as a last-ditch effort to avoid femoral access and a high likelihood of increased catheter manipulation if we had chosen to snare the distal end of the catheter from the left radial approach. Ultimately, the pressure was held for 12 seconds using intermittent fluoroscopy; however, it could have taken a much longer time, which could have altered our technique to unravel the kink. Thankfully, there was no significant change in the radiation dosimeter to the technologist that month as compared with previous months.
Disclosures: Richard Casazza, MAS, RT(R)(CI) reports he is Director of R&D for Tesslagra Design Solutions. Enrico Montagna, RT(R)(CI), Dr. Miller, Dr. Jayanti, and Dr. Malik report no conflicts of interest regarding the content herein.
The authors can be contacted via Richard Casazza, MAS, RT(R)(CI), at all4ugq@aol.com or on Twitter at @Tesslagra.
Read a commentary from Dr. Morton Kern here.
References
1. Burzotta F, Brancati MF, Porto I, et al. Comparison of right and left upper limb arterial variants in patients undergoing bilateral transradial procedures. Circ Cardiovasc Interv. 2015 Dec; 8(12): e002863. doi: 10.1161/CIRCINTERVENTIONS.115.002863.
2. Sciahbasi A, Frigoli E, Sarandrea A, et al. Radiation exposure and vascular access in acute coronary syndromes: the RAD-Matrix trial. J Am Coll Cardiol. 2017 May 23; 69(20): 2530-2537. doi: 10.1016/j.jacc.2017.03.018.
3. Xia SL, Zhang XB, Zhou JS, Gao X. Comparative efficacy and safety of the left versus right radial approach for percutaneous coronary procedures: a meta-analysis including 6870 patients. Braz J Med Biol Res. 2015 Aug; 48(8): 743-750. doi: 10.1590/1414-431X20154571.
4. Dominici M, Diletti R, Milici C, et al. Operator exposure to x-ray in left and right radial access during percutaneous coronary procedures: OPERA randomised study. Heart. 2013 Apr; 99(7): 480-484. doi: 10.1136/heartjnl-2012-302895.
5. Patel T, Shah S, Pancholy S, et al. Working through challenges of subclavian, innominate, and aortic arch regions during transradial approach. Catheter Cardiovasc Interv. 2014 Aug 1; 84(2): 224-235. doi: 10.1002/ccd.25418.
