Mr.A, 64 years old, came to the hospital for coroangiographyad hoc percutaneus coronary intervention (PCI). Since two months ago, thepatient had complained of chest pain while doing moderate activity, such aswalking more than 300 meters or climbing stairs. He had controlled hypertensionand diabetes mellitus. Vital signs and other physical examinations were withinnormal limitLaboratorium:Hb 11.6, Ureum: 87.50, Creatinin: 2.81, eGFR24, Random Blood Glucosa: 78 mg/dl
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Electrocardiography: Sinus rhythm, 55 bpm, no otherabnormalitiesComputed Tomography Coronary Angiography: Mild stenosismid-distal RCA, mild stenosis proximal-distal LCX. Conclusion: CAD 2 VDTreadmill Stress Test: suggestive ischemic response

Right coronary artery cannulation was uneventful. But cannulation of the left coronary was challenging due to tortuosity of  the right subclavian artery. When the Guiding Catheter (GC) EBU (Medtronic)) 3.5/6F tried to pass the right brachial artery as an exchange from TIG diagnostic catheter 5F, it encountered severe spasm. Balloon Assisted Tracking (BAT) was performed with Semi Compliant (SC) Balloon 2.0 x 15 mm inflated up to 6 atm to solve the problem.
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Several GC were used to cannulate LCA but encountered difficulties caused by severe spasm and tortuosity. When we tried to pull out the GC XB, we encountered resistance that evidently caused by the failed of J Wire to reach the distal end of the GC that eventually lead to kinking of the GC. We attempted several maneuvers to release the kinked GC but failed. We decided to do snaring from retrograde approach.
Snaring the GC XB through the right femoral artery was done with  JR 3.5/6F catheter. It was advanced retrogradely to the right subclavian artery, and placed in front of to the GC XB. The 15 mm Snare Memopart was inserted through the JR catheter but failed to snare the XB. A snare-size escalation with a 30 mm Memopart snare was performed, and successfully bind the distal end of the XB catheter. Wire J was inserted into the GC XB and maneuvered to unwind the catheter twist. After several laborious coordinated attempt, the GC XB 3.5/6F catheter was successfully pulled out from the vessel into the radial sheath. The coronary angiography procedure was resumed with JL catheter via femoral access.
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Catheter kinking is a troublesome complication in coronaryangiography or PCI procedure. Maneuvering of catheter needs to be carefullydone, especially when encountered with arterial spasm, tortuosity or othervascular anomalies. Cannulation and maneuvering with the support of guide wireinside the catheter is required to minimize the risk of catheter kinking.However, if such complication arise, we must be able to handle it. In thiscase, after several attempts to release the kink from the radial site werefailed, we then successfully snared the kinked catheter from femoral access. Insome cases in which we fail, a help from surgeon is necessary.