Preventing Kinks and Entrapments in Coronary Interventions With Innovative Approaches

Abstract

Objective

To describe a novel balloon-assisted intraluminal technique for the removal of a kinked catheter during transradial coronary angiography complicated by subclavian artery tortuosity.

Key Steps

Catheter kinking was recognized during transradial access, refractory to standard maneuvers. A retrieval attempt with snare via femoral access failed. Using multiangle fluoroscopy, a 0.014-inch BMW guide wire (Abbott) was advanced through the kinked catheter lumen. Inflation of a 2.0-mm low-profile balloon within the kinked segment provided intraluminal support. Slow inflation of the balloon allowed controlled traction and smooth catheter removal without adverse effects.

Potential Pitfalls

Vessel damage or catheter breakage may occur if aggressive manipulation is attempted without intraluminal support. Precise fluoroscopic documentation of wire placement is essential. Operator expertise is paramount; escalation from simple to complex techniques should be followed. Attention to patient selection, catheter choice, and real-time imaging reduces risk.

Take-Home Messages

Proper catheter handling, minimized manipulation, and device selection are crucial. Operator expertise ensures safe, efficient outcomes.

Graphical Abstract

As interventional cardiology continues evolving, there has been increasing support for transradial access (TRA) for coronary interventions. There was a time when TRA was considered to be a niche approach, but it has become the preferred standard among clinicians and has changed the way vascular access is performed. There are 2 key reasons for the rapid increase in its popularity: patient comfort levels are higher, and the recovery time tends to be shorter.

Take-Home Messages

• •Proper catheter handling, minimized manipulation, and careful device selection are crucial to overcoming challenges in transradial procedures.
• •Operator expertise is key to reducing risks and ensuring safe, efficient outcomes.

However, it is essential to point out that TRA is not free from challenges; there may be both minor and severe complications at the site of access, as systematically assessed in the RIVAL (RadIal Vs femorAL access for coronary intervention) trial. The study recognized several trauma consequences associated with TRA, albeit less severe than those caused by transfemoral access (TFA). Complications reported in the trial included radial artery occlusion, radial artery spasm, puncture site hematoma, and radial artery perforation.^1,2

Proper vascular closure is critical to enable interventional cardiologists to safely and effectively perform procedures using TRA or TFA and to manage any associated complications. Any complication, such as one stemming from catheter insertion and manipulation, can be detrimental to the success of the procedure and the attainment of positive clinical outcomes. While encasing kinks and knots are infrequent, they bring considerable difficulties.

In this case report, we describe the prevention of difficulties by adhering to recognized catheter retrieval protocols as well as the adoption of a unique approach that is the first of its type to be devised and applied.

Case Report

A 54-year-old man was referred for coronary angiography because of exertional chest pain and a positive treadmill test. He had a medical history of diabetes mellitus, hypertension, hyperlipidemia, and ischemic heart disease, for which he underwent percutaneous coronary intervention to the left anterior descending artery (LAD) in 2018. After a negative result on the modified Allen's test and with the patient's consent, we proceeded with the TRA approach, which was successful.

Coronary angiography demonstrated mild atheroma in the left main coronary artery and proximal LAD (patent stent), mid-LAD (80% stenosis with tapering distal lesions), and left circumflex coronary (mild lesions). There was also 80% stenosis of the mid and distal right coronary artery.

During catheter manipulation, the diagnostic catheter kinked and became lodged in the right subclavian artery. The initial attempts at opening the kink through gentle rotation were not successful. A 0.035-inch Teflon guide wire was passed to straighten the catheter but failed and resulted in severe patient discomfort despite adequate sedation. The snare system was then passed through the right femoral artery to catch the tip of the catheter; however, this was unsuccessful owing to the rigid positioning of the kinked segment within the vessel and the inability to position the snare loop between the deformed course of the catheter (Figure 1).

Figure 1.

Unsuccessful Snare Retrieval of the Kinked Catheter Tip via Right Femoral Access After Failed Rotational Maneuvers

An innovative technique was used after traditional retrieval procedures failed. After passing through the right femoral artery, a 6-F catheter was placed next to the kinked catheter tip into the right subclavian artery. A 0.014-inch BMW guide wire (Abbott) was steadily advanced into the distal lumen of the kinked catheter after having been selected for its floppy tip and exceptional torque ability. Its proper position was confirmed with a few fluoroscopic projections (right and left anterior oblique views) and by the evidence of buckling at the tip of the wire—an indirect sign of intraluminal involvement.

A 2.0 × 12 mm balloon was subsequently advanced over the wire and inflated within the kinked segment to provide internal support and deformity correction. Slow inflation of the balloon allowed gentle traction over the entire system, effectively decreasing the torsion and releasing the catheter into the descending aorta. A 0.035-inch Teflon wire was subsequently passed via the catheter, further assisting in untwisting and facilitating safe and total removal (Figure 2).

Figure 2.

Realignment and Balloon Dilation of the Kinked Catheter via Right Femoral Access

After removal of the catheter (Figure 3), percutaneous coronary intervention of the mid-LAD was successfully performed with a 2.5 × 22 mm Resolute Onyx drug-eluting stent (Medtronic) at 12 atm for 13 seconds, without incident.

Figure 3.

Successful Retrieval of the Kinked Catheter Using Gentle Traction

Discussion

Catheter kinking is a well-established hurdle that can occur during a TFA or TRA procedure, especially with tortuous vascular anatomy. This case demonstrates the challenges presented by catheter kinking in the setting of TRA, mainly when there is significant anatomical tortuosity.

The high possibility of catheter kinking is attributed to the tortuosity of the subclavian artery, as seen in this case. Approximately 10% of patients who undergo transradial procedures have severe tortuosity, which puts them at greater risk for this complication. Other causes of kinking are the presence of an artery smaller than the catheter, arterial spasm, and excessive catheter loops.

The following initial methods can be used to treat slight kinking of catheters or similar medical instruments: gentle traction, counter-rotational movements, and guide wire advancement. Gentle maneuvering must be executed so no further movement cuts the catheter or the surrounding tissue. However, these simple methods cannot help with more complex loops and sharp kinks. In these cases, you must explore other approaches that require advanced tactics.3, 4, 5

Described options in the literature include inflation of the blood pressure cuff on the same-side brachial area to allow for delicate undoing of the catheter, a gooseneck snare to catch and free knots in big-caliber vessels, and deployment of an endovascular snare catheter to grasp and rotate the distal and proximal ends of the kinked catheter. Cutting the catheter's hub and placing a long sheath over it for straightening the kinked segment or using balloon-assisted trapping through a large-bore sheath for removal are also effective. These approaches extend the range of possibilities for dealing safely and effectively with catheter complications, each for specific clinical situations.⁶

In our case, the technique described demonstrates a successful alternative: intraluminal balloon-supported straightening. A 0.014-inch BMW guide wire was advanced gently through the kinked catheter lumen under multiple-angle fluoroscopy. After inflation of a low-profile balloon in the kinked segment, it was employed to provide the internal support required to relieve torque and tension, allowing safe and controlled removal. The advantage of this technique is that the catheter can be straightened from the inside without external trauma and potential breakage. It is especially useful in narrow or tortuous segments such as the subclavian artery.

This technique provides an effective bailout option for catheter entrapment in anatomically restricted areas. It avoids the need for surgical intervention or catheter fracture, though it requires careful fluoroscopic visualization and operator expertise. Potential limitations include the risk of further catheter damage or vascular injury if not executed with precision.

Teaching Points

This case demonstrates a few helpful teaching points, such as the gradual, stepwise attempting of different retrieval techniques; the advantage of fluoroscopic imaging in various planes to confirm intraluminal wire placement; and the advantage of balloon-assisted straightening as a reversible and vessel-preserving bailout technique. Operators must be attuned to the dynamics of catheters on progression, particularly in tortuous anatomy, and they must have a low threshold for conversion to femoral access or advanced retrieval techniques if conventional methods fail. Frequent use of fluoroscopy and careful choice of catheter are essential in both the prevention and treatment of kinking-related complications.

Conclusions

Kinking is a rare but known complication of catheter entrapment owing to the transradial approach. Different techniques for managing such complications have been described, and in our case, a stepwise approach is also advisable. Much more common in TFA access, kinking can also result after transradial procedures.

This case illustrates the challenges of managing kinking, especially the extreme arterial tortuosity. We followed a progressive approach that started with the least invasive interventions and moved step by step to the more complex ones. In this way, the problem can effectively be established, and the incidence of surgical intervention can be reduced. Appropriate selection of patients, judicious placement of the catheter, and meticulous monitoring will help diagnose and treat kinking in transradial procedures.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.