Catheterization and Cardiovascular Interventions 85:E35–E38 (2015)
A Novel Nonpharmacologic Technique to Remove Entrapped Radial Sheath Samir B. Pancholy,1* MD, FACP, FACC, FSCAI, Poorna Rajasekhar Karuparthi,2 MD, and Rajiv Gulati,3 MD, FACC, FSCAI Radial artery access for performance of coronary and peripheral diagnostic as well as interventional procedures is on the rise. With increasing adoption comes the expected increase in procedural complications. We describe a novel, simple, and effective nonpharmacologic solution for sheath entrapment related to pharmaco-resistant radial artery spasm. VC 2014 Wiley Periodicals, Inc. Key words: vascular complications; catheterization; brachial/radial/ulnar; complications; PCI
INTRODUCTION
The radial artery is more prone to spasm compared with femoral artery, in part due to a bulky muscular tunica media. Severe spasm leads to discomfort, difficulty in catheter navigation, and is the second most common reason for procedural failure [1]. Radial artery introducer sheath entrapment is a rare but dreaded complication of transradial access (TRA), usually a result of severe spasm. It is associated with pain upon withdrawal of the sheath, and forced removal could result in endarterectomy or even avulsion of the radial artery [2]. We describe two cases of radial introducer sheath entrapment due to severe spasm, which were successfully treated using a simple nonpharmacologic technique, after maximal pharmacotherapy failed. CASE 1
A 67-year-old Caucasian female with history of coronary artery bypass graft surgery and end-stage renal disease presented with accelerating angina and an abnormal myocardial perfusion study. Allen test was normal bilaterally. After placement of 6 Fr Radiofocus hydrophilic sheath (Terumo Medical), the patient reported mild discomfort at left forearm, which was controlled with minimal analgesic and anxiolytic medications. Furthermore, 400 mcg of nitroglycerin, 5 mg of verapamil, and 2500 U of heparin were given through the sheath. Patient underwent diagnostic catheterization using 6 Fr catheters. There was moderate difficultly in selective engagement of coronary arteries, due to marked tortuosity of the aorta, requiring multiple catheter exchanges. Significant stenoses were identified in a medium sized ramus intermedius artery (RI) and distal right C 2014 Wiley Periodicals, Inc. V
coronary artery (RCA). Attempts to engage left coronary artery with JL4 and JL 4.5 guide catheters were unsuccessful. Percutaneous coronary intervention (PCI) of proximal RI and distal RCA were subsequently performed using 6 Fr catheters. Mild discomfort in the left upper extremity was noted with catheter exchanges over an 0.3500 J-tipped guide wire. Patient received additional doses of fentanyl and versed to ensure moderate sedation, in addition to 7500 U of heparin before the initiation of intervention. Total procedure duration was 225 min, fluoroscopy time was 25.7 min, and 140 mL of radiocontrast was administered. Following intervention, the guide catheter was removed without significant resistance or pain, but significant resistance was felt at the time of attempted withdrawal of the radial sheath, along with moderate to severe discomfort in the left forearm. Additional sedation, waiting, and retrying, nitroglycerin 500 mcg and verapamil 5 mg were given intra-arterially through the 1
The Wright Center for Graduate Medical Education, The Commonwealth Medical College, Scranton, Pennsylvania 2 Borgess Medical Center, Michigan State University, Kalamazoo, Michigan 3 Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, Rochester, Minnesota Conflict of interest: Samir B. Pancholy: Terumo (Consultant). *Correspondence to: Samir B. Pancholy, MD, FACP, FACC, FSCAI, 401, N. State Street, Clarks Summit, PA 18411. E-mail: [email protected] Received 26 March 2014; Revision accepted 6 July 2014 DOI: 10.1002/ccd.25593 Published online 9 July (wileyonlinelibrary.com)
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left radial sheath, were ineffective. Intravenous nitroglycerine drip was also initiated. Angiogram through the left radial sheath showed good flow in ulnar artery and proximal portion of the radial artery. Flow from ulnar artery was identified supplying the palmar arch. The diameter of the radial artery was slightly smaller compared with the introducer sheath (Fig. 1). Physical examination revealed, intact neurovascular status of left hand. Left fingers were warm, capillary refill of
A Novel Nonpharmacologic Technique to Remove Entrapped Radial Sheath Samir B. Pancholy,1* MD, FACP, FACC, FSCAI, Poorna Rajasekhar Karuparthi,2 MD, and Rajiv Gulati,3 MD, FACC, FSCAI Radial artery access for performance of coronary and peripheral diagnostic as well as interventional procedures is on the rise. With increasing adoption comes the expected increase in procedural complications. We describe a novel, simple, and effective nonpharmacologic solution for sheath entrapment related to pharmaco-resistant radial artery spasm. VC 2014 Wiley Periodicals, Inc. Key words: vascular complications; catheterization; brachial/radial/ulnar; complications; PCI
INTRODUCTION
The radial artery is more prone to spasm compared with femoral artery, in part due to a bulky muscular tunica media. Severe spasm leads to discomfort, difficulty in catheter navigation, and is the second most common reason for procedural failure [1]. Radial artery introducer sheath entrapment is a rare but dreaded complication of transradial access (TRA), usually a result of severe spasm. It is associated with pain upon withdrawal of the sheath, and forced removal could result in endarterectomy or even avulsion of the radial artery [2]. We describe two cases of radial introducer sheath entrapment due to severe spasm, which were successfully treated using a simple nonpharmacologic technique, after maximal pharmacotherapy failed. CASE 1
A 67-year-old Caucasian female with history of coronary artery bypass graft surgery and end-stage renal disease presented with accelerating angina and an abnormal myocardial perfusion study. Allen test was normal bilaterally. After placement of 6 Fr Radiofocus hydrophilic sheath (Terumo Medical), the patient reported mild discomfort at left forearm, which was controlled with minimal analgesic and anxiolytic medications. Furthermore, 400 mcg of nitroglycerin, 5 mg of verapamil, and 2500 U of heparin were given through the sheath. Patient underwent diagnostic catheterization using 6 Fr catheters. There was moderate difficultly in selective engagement of coronary arteries, due to marked tortuosity of the aorta, requiring multiple catheter exchanges. Significant stenoses were identified in a medium sized ramus intermedius artery (RI) and distal right C 2014 Wiley Periodicals, Inc. V
coronary artery (RCA). Attempts to engage left coronary artery with JL4 and JL 4.5 guide catheters were unsuccessful. Percutaneous coronary intervention (PCI) of proximal RI and distal RCA were subsequently performed using 6 Fr catheters. Mild discomfort in the left upper extremity was noted with catheter exchanges over an 0.3500 J-tipped guide wire. Patient received additional doses of fentanyl and versed to ensure moderate sedation, in addition to 7500 U of heparin before the initiation of intervention. Total procedure duration was 225 min, fluoroscopy time was 25.7 min, and 140 mL of radiocontrast was administered. Following intervention, the guide catheter was removed without significant resistance or pain, but significant resistance was felt at the time of attempted withdrawal of the radial sheath, along with moderate to severe discomfort in the left forearm. Additional sedation, waiting, and retrying, nitroglycerin 500 mcg and verapamil 5 mg were given intra-arterially through the 1
The Wright Center for Graduate Medical Education, The Commonwealth Medical College, Scranton, Pennsylvania 2 Borgess Medical Center, Michigan State University, Kalamazoo, Michigan 3 Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, Rochester, Minnesota Conflict of interest: Samir B. Pancholy: Terumo (Consultant). *Correspondence to: Samir B. Pancholy, MD, FACP, FACC, FSCAI, 401, N. State Street, Clarks Summit, PA 18411. E-mail: [email protected] Received 26 March 2014; Revision accepted 6 July 2014 DOI: 10.1002/ccd.25593 Published online 9 July (wileyonlinelibrary.com)
2014
in
Wiley
Online
Library
E36
Pancholy et al.
left radial sheath, were ineffective. Intravenous nitroglycerine drip was also initiated. Angiogram through the left radial sheath showed good flow in ulnar artery and proximal portion of the radial artery. Flow from ulnar artery was identified supplying the palmar arch. The diameter of the radial artery was slightly smaller compared with the introducer sheath (Fig. 1). Physical examination revealed, intact neurovascular status of left hand. Left fingers were warm, capillary refill of
