Employment of the transradial approach for percutaneous coronary intervention (PCI) has gained immense popularity amongst interventional cardiologists as compared to the transfemoral technique. Various advantages offered by the former include decreased bleeding, improved patient satisfaction, decreased length of hospital stay and improved economic outlook. The procedure is usually conducted uneventfully. However, when complications do occur, the consequences could be serious. One among these dreaded events is the entrapment of guidewire employed for the placement of catheters (diagnostic/therapeutic) for hooking of coronary ostium.[1]
A 34-year-old male patient, 170 cm tall and weighing 70 kg, presented to the emergency department with acute onset angina for 6 h. A sublingual tablet of isosorbide dinitrate (5 mg) provided prompt symptomatic relief. Physical examination was unremarkable. He was maintaining haemodynamically stable vitals. An electrocardiogram was suggestive of ST-T segment elevation in V2-V6 with corresponding changes in inferior leads. Two-dimensional echocardiography revealed mild hypokinesia along the apex in addition to left ventricular regional wall motion abnormalities and an ejection fraction of 45%. A troponin I report suggested a positive result. A provisional diagnosis of anterior wall STEMI was established. The patient was urgently loaded with a combination of “aspirin (300 mg)-ticagrelor (180 mg)-atorvastatin (80 mg)” and the cardiac catheterisation laboratory was activated.[2]
Prior to initiating a coronary angiogram, fentanyl at 1 μg/kg body weight was administered to the patient intravenously. Oxygen was supplemented via nasal prongs. A 6 Fr sheath (Radifocus® Introducer II - Terumo, India) was introduced by the Seldinger technique into the right radial artery. A quick right coronary angiogram revealed a normal right coronary. As it was a case of suspected anterior wall MI, a direct extra backup (EBU) guiding catheter (Medtronic) was utilized for left coronary artery assessment. As the operator was attempting to manoeuvre the EBU guiding catheter up to the aorta, the patient moaned with pain in his right arm. The radial artery had developed a spasm and the guidewire had looped in its course along the radial artery. [Figure 1] Any further manipulation of the guidewire was unsuccessful due to the persistent arterial spasm. On fluoroscopy, the guidewire was visualised to form a 'figure of eight'. Thereafter, a cocktail of intra-arterial vasodilators (lignocaine 80 mg, nitroglycerin 1 mg, diltiazem 50 mg mixed in 100 ml normal saline) was administered in incremental doses of 8 ml each. Eventual endeavours by the cardiologist to retrieve the guidewire by applying considerable traction failed. Help from anaesthesia was sought at this stage. The plan was to administer propofol intravenously in incremental doses in an attempt to dilate the vessel. The spasm gradually subsided upon giving propofol in aliquots to a total of 100 mg intravenously and fentanyl 1 μg/kg body weight intravenously. The cardiologist was able to push the entangled guidewire towards the aorta. However, it was discovered that the guidewire had wrapped at 180° along its own axis generating a loop at the junction of the extremely malleable distal 8–10 cm tip and the residual of the guidewire. Hence, a 6 Fr long sheath was advanced over the trapped guidewire through the radial artery until the point of kinking under fluoroscopy. The lodged guidewire was gradually retracted and slid into the sheath. Both the guidewire and sheath were then removed en bloc successfully without any complication. Owing to the enhanced expertise of the cardiologist, the time taken to retrieve the lodged device after our intervention and aid was about 10–15 min. The patient continued to display stable vitals throughout the remainder of the retrieval procedure. As the cardiologist was unable to visualise the left coronary artery in this setting, the patient was planned for an angiography the subsequent day. However, the left anterior descending artery, left main coronary artery and the left circumflex artery revealed a normal anatomy. The patient was discharged with stable vitals with an advice to consume antiplatelet, beta-blockers and statins and to follow up with further blood assays to evaluate the cause of the ACS.
Figure 1.
“Figure of 8” appearance of guidewire after repeated attempts at retrieval
Radial artery spasm (5% to 30%)[1] functions as one of the most notorious barriers impeding regular use of the radial approach to PCI. It is more common in younger age, female gender, diabetics, underweight, repeated catheter manipulations, bigger sheath size and operator naivety. Vasoconstriction results from the stimulation of alpha-1 more than alpha-2 adrenoreceptors by catecholamines. Intense spasm as well as application of an aggressive torque to the catheter can both culminate in catheter entrapment. Crude movements resulting in rotation of the catheter beyond 180° could lead to a surge in the level of torque proximally.[3] This can diminish the operator's control over the catheter behaviour leading to kinking and looping. Once a spasm sets in, it is handled with doses of arterial vasodilators, enhanced analgesia, sedation. Techniques like sedation with propofol, regional block of axillary nerve and general anaesthesia have been employed to facilitate a lodged-catheter removal. Removal via percutaneous and surgical route, and even leaving the wire fragments in situ have been cited techniques.
In our case, the patient had an amplified catecholamine release consequent upon anxiety, episode of angina, reduced temperature of the catheterization laboratory and probably local site pain due to insufficient local anaesthetic infiltration during insertion and manipulation of the catheter. We used propofol intravenously in aliquots and this probably relieved the spasm by diminishing the sympathetic drive and reducing the catecholamine surge. Hence, we suggest that if feasible, this may be used as a resort to relieve spasm of the radial artery during percutaneous interventional procedures. However, caution must be exercised in patients with a full stomach, in which case, airway protection may be compromised. In such cases, regional techniques like axillary block may be tried.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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REFERENCES
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