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Vascular Access (transradial) - Vascular Access
A Case of a Notorious Knot in Transradial PCI
Fathima Aaysha Cader1, Saidur Rahman Khan1
Ibrahim Cardiac Hospital & Research Institute, Bangladesh1,
[Clinical Information]
- Patient initials or identifier number:
-Relevant clinical history and physical exam:
A 50 year-old Bangladeshi female on optimum GDMT presented with CCS Class III angina for 6 weeks. She was diabetic and hypertensive. She was haemodynamically stable with pulse of 76 beats/min and BP of 120/70 mmHg. 
-Relevant test results prior to catheterization:
Her ECG showed ST depressions and T inversions in leads II, III and aVF, consistent with infero-lateral ischaemia. Echocardiography showed an LV EF~50% with inferior wall hypokinesia. Serum cretinine was 0.97 mg/dL. Other biochemistry were within normal limit. 

- Relevant catheterization findings:
Coronary angiography by right radial access revealed significantly diseased LAD & RCA. We planned a PCI to RCA first followed by PCI to LAD. PCI to RCA was done using JR 3.5 6 F guide catheter by right radial approach and 3.0x 23 mm DES was deployed. Next, for PCI to LAD, the JR guide was exchanged for JL 3.5 6 F guide catheter with 0.032” wire. 
[Interventional Management]
- Procedural step:
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. 

- Case Summary:
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. 
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