Complete fracture of a guiding catheter is a rare complication of percutaneous coronary intervention (PCI).1–4 It has been reported to occur during excessive twisting of the catheter, especially when attempting to engage the right coronary artery via the transradial approach.1 Extraction of a fractured guiding catheter is a necessity, because it invariably leads to limb ischaemia. Options for retrieval of remnants of coronary angioplasty equipment include endovascular retrieval devices or surgery.3,4
We report a rare case of a fractured guiding catheter with its tip in the ascending aorta and its successful retrieval using a combination of home-made snare, kissing guiding catheter and balloon trekking technique.
Case Report
A 94-year-old man with diabetes, hypertension and hyperlipidaemia presented with an anterior ST-elevation MI. Primary PCI was performed.
The right radial approach was obtained using a 6 Fr sheath. An Ikari Left (IL) 3.5 6 Fr guiding catheter (Terumo Interventional Systems) was successfully advanced into the ascending aorta despite tortuosity in the radial artery (Figure 1A). During attempts at engaging the right coronary artery, there was difficulty manipulating the guiding catheter and loss of pressure tracing.
Fluoroscopy of the right arm showed ‘knotting’ of the guiding catheter below the level of the elbow. Attempts to untwist the catheter by anchoring the catheter above the twisted segment with an inflated blood pressure cuff and direct manual compression were unsuccessful. Further untwisting applied to the proximal catheter resulted in a ‘give’, as the catheter completely fractured at the kink. The proximal portion of the fractured catheter (approximately 40 cm) was removed through the radial sheath. The distal portion of the guiding catheter was left behind with its tip in the ascending aorta (Figure 1B) and its proximal end in the radial artery below the cubital fossa (Figure 1C).
We decided to proceed with the primary PCI before returning to deal with the fractured catheter. Right femoral access was obtained using a 6 Fr sheath. The mid left anterior descending artery (infarct-related artery) was successfully treated with a Resolute Onyx 2.75 × 38 mm drug-eluting stent (Medtronic), establishing Thrombolysis in MI grade 3 coronary flow (Supplementary Figure 1).
Attention was then returned to retrieving the retained broken guiding catheter. The 6 Fr femoral sheath was upsized to a long 35 cm 9 Fr Brite Tip sheath (Cordis), with the intention to remove the fractured catheter transfemorally. As we did not have a large endovascular snare device at hand, we proceeded to use an improvised snaring device. An XB2 6 Fr guiding catheter (Cordis) was advanced from the femoral sheath to the ascending aorta near the fractured catheter tip. The small XB2 curve readily unfolded in the ascending aorta, thus pointing up towards the tip of the broken IL 3.5 guider. A Sion wire (Asahi Intecc) was introduced into the XB2 guiding catheter as a loop and trapped at the distal tip of the catheter with a 2.25 × 15 mm balloon (Sapphire II Pro; OrbusNeich), creating a snare with adjustable loop diameter (Figure 2A). After a few attempts, the distal end of the IL 3.5 catheter was captured by the snare (Figure 2B) and successfully pulled to the descending aorta. Not surprisingly, the IL 3.5 catheter did not enter the femoral sheath, as they were not coaxial (Figure 2C).
During the subsequent manipulation of the snaring catheter, it was observed that the tips of the guiders were touching quite frequently, thus confirming their proximity. We confirmed on several fluoroscopic views that the IL 3.5 and XB2 guiding catheters were in close proximity with their tips aligned. The snaring wire and Sapphire balloon were removed. A Sion Blue wire (Asahi Intecc) was introduced via the XB2 guiding catheter into the aorta and retrogradely advanced into the tip of the fractured IL 3.5 guiding catheter without much difficulty (Figure 3A and Supplementary Video 1). A 2.25 × 10 mm balloon (Sapphire II Pro) was delivered via this wire and inflated in the IL 3.5 guiding catheter to anchor it. This brought the IL 3.5 catheter to the tip of the femoral sheath, but was still not coaxial, with the catheter abutting against the edge of the 9 Fr sheath.
Finally, this short 10 mm balloon was replaced with a longer 30 mm balloon (Pantera Pro 2.5 × 30 mm balloon; Biotronik) and advanced halfway into the IL 3.5 guiding catheter. This was positioned such that it was only partially within the catheter tip, with the other half of the inflated balloon exposed outside the catheter. This set-up is similar to the well-described balloon-assisted trekking technique.
The exposed balloon, when withdrawn with the XB2 guiding catheter, conjoined the two catheters and aligned the entire system with the femoral sheath. The tip of the IL 3.5 guiding catheter entered the 9 Fr femoral sheath, thus enabling the broken catheter to be removed successfully through the sheath in a coaxial fashion (Figures 3B and 3C, and Supplementary Video 2). A final femoral angiogram showed no trauma to the femoral artery.
Discussion
Complete fracture of a guiding catheter is a rare complication of PCI.1,5–7 They are reported less frequently than guidewire fractures, which have a low estimated incidence of 0.1–0.2%.3 Of the limited literature, fractured catheters occur more commonly via a transradial rather than transfemoral approach, which is likely to be due to smaller vessel calibre and higher likelihood of the catheter twisting on itself.1,6,8 Diagnostic and guiding catheters are both prone to fractures, with causal factors including excessive torquing, forceful manipulation across a narrow stenosis or spasm, repeat catheter usage and equipment-related issues, such as polymer ageing.1,6–9
The Ikari guide is made of the same structural composition as other commercially available guiding catheters, and does not appear to demonstrate an equipment-related predilection for fracture. We illustrate a case where significant radial artery tortuosity resulted in an IL 3.5 guiding catheter twisting on itself during manipulation and eventually completely fracturing into two pieces when traction was delivered.
Options for retrieval of a fractured guiding catheter include the use of endovascular retrieval devices or, failing which, surgery.1,5,6 In our case, we successfully employed a novel transfemoral approach, as described above.
The difficulty in our case was guiding the catheter into the femoral sheath. Conventionally, in cases of fractured guidewire or balloon catheter, an endovascular retrieval device could pull the fractured material into a femoral or radial sheath. As the catheter and femoral sheath were not coaxial, the 6 Fr guiding catheter could not be withdrawn into the 9 Fr femoral sheath, which was the largest sheath available in our laboratory. If we had forcibly removed the catheter without it being encased in the sheath, it might have damaged the femoral arterial wall, resulting in arterial haematoma or incomplete removal of the catheter.
Our approach of retrogradely wiring the fractured guiding catheter was easier than anticipated. While the approach was seemingly driven by luck, a few pointers could increase the chance of success and reproducibility of this strategy. First, localising the working field to a vessel of smaller calibre (such as the common femoral artery rather than the ascending aorta) to limit space and bring the two guiding catheters closer together. Second, appreciation of the interaction between the two guiding catheters on multiple angiographic views before choosing the most optimal view for wiring. Third, choosing a ‘rescue’ guide catheter with a gentle curve that would allow easy unfolding and alignment of the catheters.
Theoretically, our approach of retrograde wiring can be performed with a smaller-sized femoral sheath that is compatible with the 6 Fr guiding catheters, although we would recommend upsizing the sheath to allow for more room for manipulation. An even larger-sized sheath may have allowed for gross retrieval of the catheter without precise coaxiality, although this is at the expense of higher bleeding risk and should be considered in conjunction with a vascular closure device.
The objective of snaring the catheter to the descending aorta was to allow more space for guider manoeuvrability and a bigger sheath size as compared with a transradial approach. However, by changing the working field to the descending aorta, failure of percutaneous retrieval would have potentially resulted in abdominal surgery instead of a brachial cut-down.
Operators should be familiar with snaring devices, and femoral vascular access and closure, as poor snaring technique or leaving the catheter in the descending aorta would have made the rescue attempt worse. In our case, in the event of failure of percutaneous retrieval, the next step would have been to snare the fractured catheter even closer into the common femoral artery and consider a femoral cut-down.
Finally, in the context of an acute coronary syndrome, priority should always be coronary revascularisation followed by management of the catheter complication.
Conclusion
The use of the balloon-assisted trekking with an entrapped balloon to guide it into the femoral sheath obviated the risk of vessel damage or need for surgery, and was an elegant, atraumatic method of retrieval.