We report a case of a patient in late 80s who underwent diagnostic coronary angiography for symptoms of angina. The patient has a prior history of Coronary Artery Bypass Graft surgery using left internal mammary artery (LIMA) graft to left anterior descending artery (LAD) and saphenous vein grafts to obtuse marginal and right coronary artery. The procedure was performed via the right femoral artery approach using a standard 6 French sheath (Cordis Avanti+ 11 cm) with 6 French Judkins coronary catheters. Catheter manipulation proved to be very challenging as the patient had calcified and torturous right common iliac artery, requiring the use of a hydrophilic wire in order to advance the coronary catheter. Despite changing to a long femoral arterial sheath (Cordis Avanti+ 23 cm), we could not engage the coronary ostium due to lack of catheter torque. We defaulted to the left femoral artery approach using a standard 6 French femoral sheath (Cordis Avanti+ 11 cm).
We attempted to manipulate the 6 French Judkins Right 4 (JR4) coronary catheter to left subclavian artery in order to study the LIMA graft to LAD. After prolonged unsuccessful manipulation, we noticed the arterial pressure trace disappeared and the JR4 catheter became very difficult to mobilise.
Fluoroscopy revealed that the JR4 catheter was twisted to form a knot in the left common iliac artery (). An attempt at ‘untwisting’ manoeuvre was unsuccessful and had actually made the kinking worse with the catheter now twisted at two segments (). The JR4 catheter could not be mobilised at all. Despite using the stiff end of the standard 0.0035 inch guide wire to untwist the knot, it remained.
We then decided to use the Amplatz Goose Neck snare catheter to retrieve this twisted catheter via the right femoral approach. Cordis 23 cm right femoral sheath was exchanged for a Balkin Up & Over Contralateral Flexor with Radiopaque band sheath (Cook medical) (). This sheath is often used by vascular radiologist to perform vascular intervention over the opposite side of the lower limb. It has a hydrophilic coating, which eased navigation through the calcified artery. Its configuration facilitates positioning over the contra-lateral iliac artery and would be ideal to retrieve the JR4 catheter inserted from the opposite femoral artery. In addition, it is a long sheath with the length from the base to the curve of 40 cm. This allowed it to go beyond the torturous right common iliac artery. A 6 French Amplatz Goose Neck snare catheter was advanced via the Balkin femoral sheath to the ascending aorta. The ‘trap’ of Amplatz Goose Neck snare was positioned overlying the tip of the JR4 catheter (). The ‘trap’ was then closed, gripping the tip of the catheter ().
Balkin up and over contralateral flexor with radiopaque band sheath.
Snare loop positioned over catheter tip.
Tip of catheter successfully snared.
The Amplatz Goose Neck catheter was pulled, dragging down the JR4 catheter to the distal descending aorta/right common femoral artery junction (). Traction was applied to Amplatz catheter to straighten out the twisted JR4 catheter and at the same time, the Balkin sheath was advanced fully into the body, providing counter traction over the Amplatz catheter (). This countertraction manoeuvre pulled the Amplatz Snare catheter together with the tip and proximal JR4 catheter into the Balkin sheath. It was imperative to ensure that the Amplatz catheter snared the JR4 catheter at the tip to minimise the overlapping thickness, thus allowing entry into the 6 French Balkin sheath (). The whole snare kit and the proximal part of JR4 catheter was then pulled out of the body via the Balkin sheath.
Tip of coronary catheter pulled towards the Amplatz snare catheter.
Traction applied to straighten the twisted segments.
The coronary catheter pulled into the Balkin catheter.
The distal (port) end of the JR4 catheter was cut with scissors to remove the port. This was to allow passage of the distal part of JR4 catheter into the left femoral artery sheath, left iliac arteries, right iliac arteries and out of the body via the right Balkin femoral sheath. The retrieval of the JR4 catheter was completed, with the two twisted segments clearly visible ().
We successfully completed the coronary angiography via the right femoral approach using the Balkin sheath.