Percutaneous Retrieval of a Fractured Guide Catheter Using Contralateral Snaring

ABSTRACT: Guide catheter kinking and fracture is an uncommon complication of percutaneous coronary intervention and may require emergency surgical intervention if percutaneous retrieval fails. We present a case of guide catheter kinking and fracture during attempts to engage the left main coronary artery in a patient with marked iliac tortuosity. The retained guide catheter fragment was retrieved percutaneously by using a snare from the contralateral femoral artery and removing the “folded-over” catheter fragment through the contralateral arteriotomy.

J INVASIVE CARDIOL 2012;24(8):E176-E178

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Kinking of the guide catheter is an infrequent complication that usually resolves easily after inserting a guidewire through the kinked segment (Table 1). We describe a case in which guide catheter kinking resulted in guide catheter fracture. The entrapped guide catheter fragment was successfully snared and retrieved in a “folded-over” configuration through contralateral femoral access.

Case Report. An 82-year-old man with a history of multivessel coronary artery disease, diabetes, hypertension, congestive heart failure and end-stage renal failure on hemodialysis presented with unstable angina. Diagnostic angiography revealed diffuse disease in the right coronary artery (RCA) and a 90% ostial circumflex lesion. He was referred for percutaneous coronary intervention of the RCA lesion.

Right femoral arterial access was obtained using an 8 Fr, 12 cm long sheath. We attempted to engage the RCA with an 8 Fr JR4 guide catheter, but the catheter motion was not transmitted to the tip.  Fluoroscopy showed kinking of the JR4 guide catheter (Figure 1A). We were unable to straighten the guide catheter in spite of using gentle counter-clockwise rotation. During attempts to advance multiple guidewires though the kink (Figure 1B) the guide catheter separated into 2 pieces - one remained in the patient wedged to the femoral arterial sheath and the second came out (Figure 1C). We were unable to advance a guidewire through the right femoral artery sheath. Thus, we obtained contralateral arterial access and the broken guide catheter piece was snared using a 12-20 mm Ensnare (Merit Medical) (Figure 1D). We were able to dislodge the fracture catheter from the right femoral arterial sheath (Figure 1E), but it then became entrapped in the left femoral sheath (Figure 1F). We were unable to snare the proximal part of the broken piece through the right femoral artery, in spite of exchanging for a 22 cm long sheath and using multiple snares (Figure 2A). We obtained right radial access and were able to snare the distal tip of the broken guide catheter but could not withdraw it, as the snare kept on slipping off the catheter (Figure 2B).

We removed the left femoral sheath with the snare and the "bent-over" sheath through the left femoral arteriotomy (Figures 2C and 2D), cut the guide catheter, and inserted a 0.035 guidewire through the guide catheter lumen into the aorta. Following removal of the guide catheter fragments, a 9 Fr sheath was inserted into the left femoral artery achieving good hemostasis. The right external iliac had mid non-flow limiting irregularies at the site of the retrieval attempts (Figure 2E). No injury of the left femoral artery could be identified (Figure 2F). The patient tolerated the procedure well, but cardiac intervention was postponed, given the above complication.

Discussion. This case illustrates a creative solution to the uncommon complication of guide catheter fracture and loss, by snaring the guide catheter and removing the folded-over catheter from the contralateral groin.

Guide catheter fracture likely occurred due to a combination of over-rotation, repeated attempts to pull the catheter back into the sheath, and attempts to advance a guidewire through the kinked segment. Similar to our case, most catheter kinks occur during attempts to engage the RCA and resolve with counter-clockwise rotation. Guide catheter kinking should be suspected when the arterial pressure waveform disappears and the catheter rotation at the hub is not transmitted to the guide catheter tip. Once the possibility of catheter kink is entertained, fluoroscopy of the pelvis and groin can help localize and treat it. Subsequent rotation of the catheter should be minimized. In most cases, advancing a 0.035-inch guidewire will straighten the kink and allow exchange for another catheter. We have found that a 0.069-inch guidewire can also be helpful in this maneuver. The kinked catheter should not be pulled forcefully through the femoral arterial sheath, because it will not usually enter it and moreover it can become entrapped and transected, as in our case.

Once guide catheter fracture occurs, retrieval can be challenging as described in our case. There are several treatment possibilities (Table 1): (1) snaring from the ipsilateral groin (failed in our case due to tortuosity); (2) snaring from the contralateral groin (successful in our case); (3) snaring from the radial or brachial access to allow guide catheter straightening (failed in our case); or (4) pulling both the sheath and the attached guide catheter fragment (the catheter is then cut and a 0.035-inch guidewire is inserted).

In our patient we snared the entrapped guide catheter fragment from the contralateral groin, but could not snare its distal or proximal tip. We removed the “folded over” catheter from the contralateral groin, cut the catheter and inserted a 0.035 guidewire through it to maintain arterial access while the catheter fragments were removed. This maneuver carries the risk of arterial access injury as it involves pulling the folded over catheter through the arteriotomy site; however, a 9 Fr sheath successfully obtained hemostasis and iliac angiography at the end did not demonstrate any injury.

In summary, prevention of guide catheter fracture is important. If it occurs, snaring through contralateral arterial access and removal of the folded catheter through the left arteriotomy can result in successful removal of the guide catheter fragment.

Acknowledgment. We are grateful to Mr Bruce M. Morris from the Medical Media department of VA North Texas Healthcare System for his expert assistance with the images.

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From the VA North Texas Healthcare System, Dallas, Texas.    
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Michael is supported by a Cardiovascular Training Grant from the National Institute of Health, Award Number T32HL007360. Dr. Banerjee reports speaker honoraria from St Jude Medical, Medtronic, Johnson & Johnson, Boehinger, Sanofi, Mdcare Global; research support from Boston Scientific and The Medicines Company. Dr Brilakis reports speaker honoraria from St Jude and Terumo; and research support from Abbott Vascular and Infraredx; he discloses that his spouse is an employee of Medtronic.
Manuscript submitted March 8, 2012, provisional acceptance given March 30, final version accepted April 10, 2012.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216.  Email: esbrilakis@yahoo.com