Guidewire Entrapment during Radial Approach for Coronary Angiography . A Rare Complication

Radial artery access is quickly becoming the preferred route of intervention, as more and more operators are becoming familiar with it. It is associated with a decreased incidence of bleeding and other access site complications when compared with the femoral artery approach. A common complication associated with radial artery catheterization is radial artery spasm that can result in catheter entrapment or sheath entrapment.10 A few cases of radial artery avulsion due to entrapment of radial sheath have also been reported.11 As far as the guiding wires are concerned, the usual cases reported are of 0.014” guide wire entrapment in coronary arteries during percutaneous coronary interventions (PCI) 0.034” Guidewire entrapment in radial artery however, as seen in our case is a rare phenomenon. Luckily , there was no further complications due to it but the entrapped guidewire could have resulted in perforation of the main radial artery or of one of the branches where it got stuck. Secondly a fragment of the wire may also fracture and get further entrapped in one of the side branches causing occlusion of that branch.


INTRODUCTION:
Cardiac catheterization was first performed in 1929 by Werner Forssmann on himself.
Selective coronary angiography was described by Mason Sones in the early 1960s 1 . Cardiac catheterization has evolved over a long time into its current form. Even though the first trans-radial angiography was reported by Campeau et al in 1989, 2 it was followed up very quickly by the first trans-radial coronary artery stenting by Kiemeneij and Laarman in 1993. 3 The radial artery approach for cardiac catheterization in recent days has become more favorable in the hands of experienced operators. The main reason behind this is reduced access site complications as compared to femoral artery punctures. [4][5][6] Radial artery access also allows the advantage of early mobilization of the patient and improved patient comfort. Lesser complications in turn result in shorter hospital stay. Discharge on the same day is also possible that decreases the overall cost significantly. 7,8 . Patients themselves prefer the radial route due to the convenience and follow up care. In RIVAL study 90% of the patients who had undergone cardiac catheterization through radial approach reported preference for same approach if there was any need of repeat catheterization. 9 However, radial artery catheterization like the femoral is not devoid of any complications. We present a case of 0.034" guidewire entrapment in radial artery during coronary angiography.

CASE PRESENTATION
55 years old, diabetic female with an increasing frequency of angina was planned for coronary angiography. Radial artery access was planned for the procedure after a positive modified Allen's test. Under aseptic measures, 6 F radial artery sheath was passed and a 0.35" J tip guide wire was advanced through the sheath into radial artery. Just after crossing the forearm, the wire was unable to advance any further. Fluoroscopy of the fore arm showed the wire had taken an abnormal path just before brachial artery.

Figure 1 -showing that the wire has taken an abnormal path
An attempt to retrieve the wire was made through gentle traction however it was extremely painful for the patient so an alternate approach was considered. A 6 F JR diagnostic catheter was subsequently passed over the wire up to the limit to which it could be steered into the artery but it did not track the whole way. Another attempt to retrieve the wire was made with the support of the catheter but this also proved unsuccessful (Figure 2).

Figure 2 -A JR Catheter advanced over the wire for support
In order to rule out perforation of the radial artery a peripheral angiogram was performed which confirmed that the wire had taken an abnormal turn into a branch but fortunately there was no perforation. Intra-arterial nitroglycerine up to 500 mcg was given to relieve any radial artery spasm followed by another attempt at retrieval of the wire under fluoroscopy but to no benefit. A 4 F glide catheter[Terumo GLIDECATH] was then advanced on the wire into the side branch and finally this proved to be successful and the wire was retrieved through it. (Figure 3)

DISCUSSION:
Radial artery access is quickly becoming the preferred route of intervention, as more and more operators are becoming familiar with it. It is associated with a decreased incidence of bleeding and other access site complications when compared with the femoral artery approach. A common complication associated with radial artery catheterization is radial artery spasm that can result in catheter entrapment or sheath entrapment. 10 A few cases of radial artery avulsion due to entrapment of radial sheath have also been reported. 11 As far as the guiding wires are concerned, the usual cases reported are of 0.014" guide wire entrapment in coronary arteries during percutaneous coronary interventions (PCI) 0.034" Guidewire entrapment in radial artery however, as seen in our case is a rare phenomenon. Luckily , there was no further complications due to it but the entrapped guidewire could have resulted in perforation of the main radial artery or of one of the branches where it got stuck. Secondly a fragment of the wire may also fracture and get further entrapped in one of the side branches causing occlusion of that branch.
However, if such a complication does arise, there are multiple approaches that may be taken towards its management. One way is to simply apply gentle force to retrieve the wire under fluoroscopy. Localized intra-arterial vasodilators such as verapamil or nitroglycerine may be used in order to relieve radial artery spasm. Even continuous intravenous infusion of nitroglycerine 0.1mcg/kg/min can be administered in cases with severe arterial spasm according to the hemodynamics of the patient. A glide catheter can also be used as was done in our case to retrieve the wire. If all such medical and local efforts fail, then the only option left is to go for surgical retrieval of the wire.