Radial artery neuro guide catheter entrapment during mechanical thrombectomy for acute ischemic stroke: Rescue brachial plexus block

Abstract

To our knowledge, radial artery catheter entrapment during mechanical thrombectomy for acute ischemic stroke using an 8 F neuro guiding catheter (.088 in ID) and successful use of a brachial plexus block has not been described in the literature. In this technical note, we describe a patient that underwent rapid and successful radial access mechanical thrombectomy for an acute right middle cerebral artery occlusion, however, during withdrawal of the Balt Ballast 0.088 inch long sheath (Balt USA, Irvine, CA, USA), radial/brachial artery entrapment was encountered. We describe a modified step-wise approach to previously published online article by Pitta et al. from 2017 SCAI communication in the management of catheter entrapment and describe the technique for ultrasound guided brachial plexus block, which helped avoid need for surgical removal.

Introduction

Catheter entrapment for radial access procedures has been well described in the cardiology literature but potentially has a lower incidence compared to neurovascular procedures, due to the fact most cardiovascular interventions are performed using 5-7 F sheaths or direct guide catheter access with outer diameters of 2.55 mm or less. ¹ In transradial mechanical thrombectomy (MT) procedures for acute ischemic strokes in the setting of large vessel occlusion, 8 F access platforms are generally employed.² Despite direct sheathless radial access, 8 F neuro long guide sheaths have an outer diameter of approximately 2.8 mm, which is larger than the average radial artery diameter in a significant proportion of patients.³ Given increased use of arm access in stroke intervention, placement of flow diverting or intrasaccular devices, we suspect radial artery catheter entrapment will be increasingly encountered in clinical practice. Familiarity of this phenomenon and a logical stepwise approach to management is critical for any neurointerventionist performing radial access procedures.

In this report we describe the anatomic landmarks and technique to perform a brachial plexus block in the setting of catheter entrapment.

Case presentation

Late octogenarian female patient with atrial fibrillation on Rivaroxaban, hypertension, CAD, hyperlipidemia, peripheral vascular disease, that presented with severe right MCA syndrome (NIHSS 21), baseline mRS 0 and last seen well of 11.5 hours prior to presentation. Imaging including CT head with ASPECT score of 10, CTA showing right M1 occlusion, and RAPID CTP showed CBF <30 of 0 ml and Tmax >6 seconds of 108 ml (iSchemaView Inc, Menlo, Park, CA, USA).

Review of pre-procedural CTA neck showed favorable angle between the right subclavian artery and the right common carotid artery amenable to a radial first approach paradigm based on our experience (Figure 1(a)).

Figure 1.

Staged algorithm diagram.

Image 1.

(a) CTA (3 D surface reconstruction) Mild-moderate angulation between right subclavian artery/right common carotid artery junction (blue arrow) and minimal tortuosity of right common and right internal carotid arteries; favorable for radial access. (b) DSA (Pre-thrombectomy) Right ICA injection (late arterial phase) angiogram showing complete occlusion (TICI 0) M1 segment of the right middle cerebral artery (blue arrow) with pial collaterals from the right anterior cerebral artery. (c) DSA (Post-thrombectomy) Right ICA angiogram (early arterial phase) showing complete recannalization of the proximal right M1 segment of the middle cerebral artery after 1 pass after clot face aspiration using Penumbra Jet7 Flex (territory outlined by blue circle).

Image 2.

(a) Radial Catheter Entrapment at Brachial Artery: Right Axillary Artery antegrade injection (transfemoral) with microcatheter tip (black asterix) showing occlusion at junction between brachial artery and high insertion of the radial artery (blue arrow) by Balt Ballast 0.088 inch long sheath (Balt USA, Irvine, CA, USA) (dotted yellow line). (b) Post Brachial Plexus block and removal of the Balt Ballast 0.088 inch long sheath (Balt USA, Irvine, CA, USA): Right Axillary Artery antegrade injection (transfemoral) tortuosity/kink at junction between brachial artery and high insertion of the radial artery (blue arrow) with associated injury (no dissection/extravasation). (c) Ultrasound - Right Brachial Plexus (supraclavicular approach): US gray-scale image with typical “snowman” appearance of the brachial plexus (outlined in dotted yellow line). Color doppler (green rhomboid) proving no vasculature (subclavian artery lies medial to plexus for supraclavicular approach). (d) Ultrasound – Needle/Local Anesthetic: 20 cc Bupivacaine 0.25% around the brachial plexus (outlined in blue). Blue arrow showing position of the 1st rib (echogenic curvilinear line). Needle trajectory outlined in Asterix (tip small Asterix and proximal large Asterix); away from lung.

Monitored anesthesia care (MAC) using a propofol infusion initiated. Pre-puncture arm ultrasound demonstrated radial artery with diameter of 2.4 mm. After uneventful Cook 4 F micropuncture access (Cook Medical, Bloomington, IN, USA) a radial angiogram was performed demonstrating high origin of the radial artery from the mid-brachial artery. After intra-arterial administration of a radial cocktail (100 micrograms nitroglycerin, 2.5 mg verapamil, and 4000 U heparin), the micropuncture sheath was exchanged for a Balt Ballast 0.088 inch long sheath (Balt USA, Irvine, CA, USA) over a Terumo 0.035 in angled glidewire (Terumo Medical Corp, Somerset, NJ, USA) with minimal resistance.⁴ After advancing the Ballast to the axillary/subclavian junction, the dilator was removed and after a double flush the guide was attached to continuous flush with a Tuohy. The Ballast was then advanced into the mid-cervical right internal carotid artery over a 6 F Bern diagnostic catheter/glidewire (without access of the aortic arch). Using a Penumbra 0.071 Jet Flex (Penumbra Inc, Alameda, CA, USA) and a Boston Scientific Fathom 0.016 in 200 cm microwire (Boston Scientific, Marlborough, MA, USA) direct clot face aspiration using the Penumbra Engine Pump (Penumbra Inc, Alameda, CA, USA) resulting in single pass complete TICI 3 revascularization in 10 minutes from radial access (Figure 1(a) and (b)).

During withdrawal of the Ballast guide catheter significant resistance was encountered at the junction between the right subclavian-axillary artery junction. Stepwise algorithm was used to remove the catheter including increased sedation, additional administration of vasodilators through the guide (although at the level of the shoulder), and subcutaneous injection of 1000 micrograms of nitroglycerin along the guide pathway from the wrist to the shoulder, without success. Femoral access was obtained to potentially to administer intra-arterial vasodilators (Image 2a), however, unsuccessful due to complete occlusion of the radial artery origin secondary to severe spasm. After review of the angiogram, however, high insertion of the radial artery into the axillary artery was identified and may have contributed to catheter entrapment (potentially exacerbating spasm and represent an anatomic focal point for vessel torsion). This anatomic variant also minimized success of flow mediated vasodilation; placement of a manual sphygmomanometer over the brachial artery promoting vasodilation and catheter release.⁵ Despite general endotracheal intubation and waiting approximately 30 minutes, the catheter remained entrapped.

Finally, decision was made to pursue ultrasound guided supraclavicular approach right brachial plexus block, which has been previously reported by Fitzgerald, et al in the setting of transarterial cardiac catheterization.⁶ The technique for ultrasound brachial plexus blocks have been well described in the literature and tutorials are readily available on-line.⁷ In summary, ultrasound helped identified the right brachial plexus and chose an optimal trajectory to avoid the right subclavian artery (Image 2c) and lung/pleura (Image 2d). 25-gauge three inch needle was first advanced cranial to the brachial plexus and after negative aspiration, local anesthetic injected as the need was withdrawn. Second pass caudal to the brachial plexus resulting in local anesthetic surrounding the plexus (Image 1d. outline in blue) with a total of 20 cc 0.25% bupivacaine was injected. Resistance to removal of the long sheath was encountered at 10 minutes, however, 20 minutes after the block, gentle traction was applied and the sheath was easily withdrawn. If the neurointerventionalist does not have experience or comfort performing a brachial plexus block, most anesthesia departments can perform the procedure. ⁶

Patent hemostasis achieved at the radial access site with a Terumo TR radial compression band (Terumo Medical Corp, Somerset, NJ, USA) and manual compression of the 5 F femoral access (the patient did develop a groin hematoma). The was discharged to home POD 8 with NIHSS of 2 (mild facial asymmetry and confusion with date). Radial pulse was palpable at discharge without associated pseudoaneurysm or asymptomatic occlusion.

Discussion

We would like to emphasize that we have found radial artery access for neurovascular procedures to be extremely safe and this case represents a rare exception. In our combined experience over 10 years at ChristianaCare Health System, Newark DE withn over 900 procedures (>100 direct radial access procedures with .088 in guiding catheters) this was the first case we had to employ general endotracheal anesthesia and brachial plexus nerve block for safe removal. We have never had a patient require emergent vascular surgery for catheter entrapment, compartment syndrome, vessel avulsion or digital/forearm ischemia.

We perform all radial approach anterior circulation stroke interventions using ultrasound guided singe wall radial puncture with a 21 g needle. The radial artery has higher concentrations of alpha receptors in the media of vessel wall when compared to the femoral artery and is, therefore, more prone to spasm. Factors that increase risk of radial artery spasm are increased number of access attempts, an artery/sheath ratio <1.0, and increased manipulation of the guide catheter/sheath (number of exchanges). To maximize success and minimize radial access attempts we recommend standardize use of ultrasound for radial artery and placement of a micropuncture sheath prior to placement of guiding catheter.⁸ A good general rule for most 0.88 in ID long sheaths is a radial artery diameter ≥2.5 mm. If that is not possible, we recommend evaluation of radial artery diameter more proximally up the forearm, ulnar artery diameter, or alternative access (femoral or direct carotid).

Additionally, routine micropuncture access and retrograde radial angiography decreases overall average procedure times by minimizing risk of side branches perforation, pre-procedural identification of radial variants (loops or high radial insertion) and facilitates rapid crossover to alternative access sites (before placement of a large bore guide catheter and administration of a radial cocktail/heparin). We also recommend a low threshold to use a Terumo mini-J 180 cm glide wire (Terumo Medical Corp, Somerset, NJ, USA) after radial artery angiography to quickly navigate forearm and upper arm tortuosity by minimizing risk of spasm, inadvertent side branch perforation, and vessel dissection during exchange of the micropuncture sheath for guide sheath.

In most cases, after suitable radial diameter and anatomy are confirmed a radial cocktail is administered (nitro and verapamil) through the micropuncture sheath. Direct radial access is obtained after exchange of the micropuncture system with a 6 F long neuro sheath over a 180 cm angled 035 in glidewire. Routine use of a large neuro sheath with an inner diameter of .088 in and outer diameter 2.8 mm allows maximum flexibility in the thrombectomy technique including primary direct clot face aspiration or stent retriever in conjunction with lesion aspiration).

Successful removal of the catheter must be balanced with risk of major radial artery injury (avulsion/compartment syndrome). Excessive tractional force on the guiding catheter can result stretching/fracture resulting in a retained fragment. ⁹ Four sequential stages in the management of radial entrapment are visually depicted and summarized in Figure 1 and Table 1 (prior to emergency open vascular surgery). Although we have no personal experience, adjunctive use of intra-arterial lubricants into the radial sheath such as Viperslide (Cardiovascular Systems Inc., St. Paul Minnesota) have been described in the literature. ¹⁰ Viperslide is a lubricant indicated for use of to reduce friction during use of atherectomy devices in complete total occlusion atherectomy procedures and is an emulsion of water, soybean oil (10%), egg yolk phospholipids (1.2%), glycerin (2.25%), and sodium hydroxide. ¹⁰

Table 1.

Staged algorithm – entrapped radial catheter.

Stage 1: Local	The first steps we generally employ include simultaneous administration of vasodilators (serial administration of IA verapamil, nitroglycerin while balancing goal blood pressure) and deepening sedation, while increasing room temperature and patient temperature (use of bear hugger under drape).
Stage 2: Moderate Intervention	Using ultrasound guidance (avoid vascular access) and negative aspiration, administration of SQ nitroglycerin (1000 micrograms) is attempted along the catheter track. No systemic effect will be encountered unless there is intravascular injection. Using a manual sphygmomanometer over the upper arm and inflation 40 mm Hg above the systolic pressure for 5 minutes and then rapidly deflated while gently retracting the retained catheter. The mechanism for action is forearm ischemia resulting in release of local vasodilators and smooth muscle relaxation.4
Stage 3: Minimally Invasive	General endotracheal anesthesia (GETA) can be employed (if the patient is note already intubated). In our institution, we routinely perform regional pain procedures including brachial plexus blocks. Brachial plexus block can be performed using ultrasound guidance.7
Stage 4: Invasive	Urgent surgical removal of the retained catheter can be performed if the first 3 step-wise staged approach fails. It is important that the operator exercise restraint and patience avoiding aggressive maneuvers including twisting or excessive force of retraction, potentially resulting in radial avulsion or a surgical emergency.9 Although not ideal, surgical removal of the catheter can be performed with high technical success -and low-long term morbidity.

We do not advocate direct radial access with a balloon guide catheter due to concern for radial or brachial artery injury during withdrawal due a larger and potentially irregular outer surface of balloon after inflation. This technique has been described in the literature by Maus et al who published a case report describing successful use of direct radial access using a balloon guide catheter for transradial stroke intervention.¹¹

Additionally, we not advocate using an aspiration catheter directly through a radial sheath in case the clot becomes “corked” and occlusive, forcing withdrawal of the aspiration catheter from a cranio-cervical vessel all the way to arteriotomy potentially resulting in cerebral or peripheral non-target embolization.

A low profile 6 F guide catheter approach may be considered in the setting of small access vessel, small distal target vessel (M2 segment middle cerebral artery) or posterior circulation strokes, the thrombectomy can be performed using smaller 6 F guiding catheter system (inner diameter of .071 in and outer diameter 2.0 mm).

In this case of catheter entrapment, there were two potential opportunities to avoid this complication:

1. Pre-puncture ultrasound would have identified a radial artery diameter 2.3 mm, which is too small to safely accommodate an 8F long sheath with OD of 2.8 mm

2. Retrograde radial angiogram would have identified that the cause of the diminutive radial artery was variant anatomy with the origin of the radial artery from the axillary artery

At both points in the procedure there was the opportunity to cross over to alternative access prior to administration of the radial cocktail/heparin.

Summary

Radial artery will likely be encountered more frequently during neurointerventional procedures due to increased use of the access site and use of larger access catheters during stroke and complex aneurysm treatment. Most cases can be readily managed without open vascular surgery using the stepwise algorithm described.

Routine use of ultrasound and a retrograde radial arteriogram represent two critical opportunities to cross over to alternative access sites (ulnar access, femoral or direct carotid). In the future, based on this experience, we will perform a brachial plexus block prior to general endotracheal anesthesia.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sudhakar R Satti https://orcid.org/0000-0001-6671-7918