After exchanging the JL guide, the catheter jumped in the ascending aorta , and in an attempt to unravel it without a wire, it led to a knot within the right innominate artery. Initial attempt to gently torque in opposite direction led to a further knot. A 0.035” wire was passed but would cross even the proximal loop but failed. Right femoral access was established, and a goose-neck snare was delivered through a JR 3.5 6 F guide towards the knot in the right subclavian artery. Meanwhile, the proximal end of knotted catheter was cut in order to facilitate withdrawal through femoral access. The knot/ distal end of catheter was caught with the snare and brought down into descending thoracic aorta. We then tried to straighten out the knot by tugging at it by snare wire. We passed an 0.032” wire further down for better support in unravelling and the partially unraveled knot was brought back up through descending thoracic aorta towards the right subclavian artery and further down to the brachial and radial artery. Finally by means of manual torqueing, the entire system including radial sheath brought out through right radial access site. PCI to LAD completed by right femoral approach with JL 3.5 6 F guide.
Preventing the formation of a knot includes avoiding aggressive rotation of the catheter, monitoring haemodynamic pressure tracings and maintaining a wire within the catheter lumen during manipulations prior to engagement are important, especially with tortuous vasculature. Once a complication is suspected, recognizing it early is paramount to tailor a retrieval approach.