Catheter Entrapment in Radial Artery

Managing Radial Artery Catheter Entrapment: A Case Study and Stepwise Approach

Transradial access for coronary angiography and interventions has become the preferred method for many procedures due to its reduced bleeding complications compared to transfemoral access. However, it’s not without its challenges. One such rare but potentially dangerous complication is **catheter entrapment in the radial artery due to severe vasospasm.** In this blog, I’ll walk through my recent case of this complication, discuss the stepwise approach to managing it, and review the relevant literature.

Case Example: Entrapment of the Catheter in a 72-Year-Old Woman

We recently treated a 72-year-old female patient with a history of Type 2 diabetes (DM), hypertension (HTN), and double-vessel coronary artery disease. The patient was scheduled for angioplasty of the left anterior descending (LAD) artery and right coronary artery (RCA) with intravascular ultrasound (IVUS).

After completing the distal LAD intervention, we found significant calcification in the proximal LAD. The minimal lumen area (MLA) of 4mm² indicated that stenting could be deferred. However, during the catheter exchange on the left side, the radial artery catheter became entrapped due to severe spasm.

When we attempted to pull the catheter, we felt the whole artery moving, causing severe pain in the patient. Despite our best efforts to disengage the catheter, it remained stuck.

Management of Entrapped Catheter: Step-by-Step

Here’s how we managed this challenging situation:

1. Sedation and Initial Pharmacologic Interventions: - Fentanyl (50mcg) and midazolam (5mg) were given for sedation. However, the spasm persisted, and the catheter remained firmly in place.
2. Spasm Relief Cocktail: - We administered a cocktail of diltiazem (5mg) and nitroglycerin (100mcg) through the sheath, hoping to alleviate the severe spasm. Unfortunately, this didn’t work either.
3. General Anesthesia and Muscle Relaxants: - At this point, we decided to intubate the patient and induce general anesthesia with propofol and atracurium (a muscle relaxant). We waited for 30 minutes to allow for muscle relaxation, but the catheter still could not be removed.
4. Further Pharmacologic Intervention and Successful Removal: - After another 30 minutes, we gave papavarin (50mg) through the sheath, and with this, the catheter was successfully removed.
Stepwise Approach to Radial Artery Catheter Entrapment This case highlights the complexity of managing catheter entrapment due to severe radial artery spasm. The stepwise approach to managing this complication is well-established in the literature and involves several stages:
Step 1: Vasodilators and Sedation The first line of defense is to use vasodilators such as verapamil (2.5-5mg) or nitroglycerin (200-600mcg). These should be combined with sedation (e.g., fentanyl and midazolam). These measures are usually effective for mild to moderate spasms.
Step 2: Non-Pharmacologic Interventions If pharmacological measures fail, consider warming techniques to reduce spasm. These include: - Forearm warming using a convective air warming system or warm towels. - Flow-mediated vasodilatation using a blood pressure cuff applied to the upper forearm for 5 minutes to induce smooth muscle relaxation.
Step 3: General Anesthesia If the spasm is refractory to the above techniques, general anesthesia should be considered. Inducing general anesthesia with propofol and muscle relaxants has been shown to relax the smooth muscle and facilitate catheter removal. This was the approach used in our case after initial sedation failed.
Step 4: Invasive Options As a last resort, in cases of truly refractory spasm, further measures such as regional nerve blocks or even surgical endarterectomy may be required. Fortunately, we were able to avoid this in our case.
Potential Complications of Radial Artery Spasm and Entrapment While rare, catheter entrapment due to severe radial artery spasm can lead to serious complications. These include: - Radial artery avulsion, which can result in significant bleeding and hematoma. - Compartment syndrome if a hematoma is not managed appropriately.

In such cases, immediate compression of the brachial artery is recommended to control bleeding, and the patient must be closely monitored for signs of compartment syndrome.

Preventing Radial Artery Spasm and Entrapment
Preventative strategies can help reduce the risk of severe radial artery spasm: - Pre-procedural evaluation using tests like Allen’s test or Barbeau’s test can assess the adequacy of collateral circulation before proceeding with transradial access. - Minimizing vessel trauma by using smaller sheaths, limiting catheter exchanges, and keeping the procedure duration as short as possible. - Managing patient anxiety, which can exacerbate spasm.

Conclusion

Radial artery catheter entrapment due to severe spasm is a rare but serious complication that requires prompt and effective management. The stepwise approach outlined in the literature—starting with pharmacologic measures, followed by non-pharmacologic techniques, general anesthesia, and, if necessary, invasive procedures—can help alleviate this complication. In our case, we successfully managed the situation using a combination of sedation, vasodilators, general anesthesia, and pharmacologic intervention.

By understanding these techniques and being prepared for such rare events, interventional cardiologists can enhance patient safety and reduce the risk of serious complications associated with transradial procedures.