桡动脉入路，造影导管又打了个大死结！

道金医学 共享病例 深度学习

声明：本讨论来源于介入并发症群及其版权所有，转载请注明出处（专家姓名+Drking道金医学）。文内观点针对特定病例，不具备广泛临床指导意义，请勿简单模仿，以免对患者带来负面影响。对于盲目模仿文中方法带来的不良后果，Drking道金医学不负任何责任。

本期主持：田恒松教授 平煤神马集团总医院

手术台上，造影管打结，求助各位专家。

出谋划策

王能（随州市中心医院）：

透视下用手捏住，使劲压紧，然后逆时针慢慢转开，实际上就是使劲压住固定好远端。

靳志涛（火箭军总医院）：

让助手透视下按压住肱动脉，就是打折段上面一丁点。

王海昌（西安国际医学中心 心脏病医院）：

要力气大一点，手大一点的助手握。这个折有点大。

靳志涛（火箭军总医院）：

别着急，同时透视看一眼导管头端，一定要确保头端不要在冠脉口搅和，防止损伤冠脉口。慢工出细活，这种弯折不会有什么事，别慌。放大倍数下透视，助手挤压固定近心端后，轻轻转动，通过转动指导究竟往哪个方向更合适。

王能（随州市中心医院）：

直接按在圈圈的上半部分就可以，绝大多数能转开。

陈国柱（新桥医院）：

如果压不住打折的远端的话，可以用血压计压迫至200mmHg以上，透视下旋转近端，如果恶化，朝相反的方向旋转。但是要慢，怕血管穿孔。

张慧玲（济宁医学院附属医院）：

把泥鳅导丝硬头送进去，逆时针转，同时往上送造影管，千万别往外拉。

肖平喜（南京医科大学逸夫医院）：

这个比我上次那个还严重，用一根PTCA导丝或者泥鳅导丝，边按照上述讲的逆时针旋转，边把导丝靠近，试图穿过去。

这个图片显示，不能轻易拉，因为拉得不好无形中产生转的效果，转得不对就有可能断掉，多体位透照下，旋转，结合轻轻拉。

大概需要逆时针五到六圈，不能过度。

陈磊磊（江苏省人民医院）：

股动脉穿刺，送指引导管，用抓捕器把导管头段捕捉固定，再旋转导管就可以解开，抽出来啦。

李晓鲁（千佛山医院）：

先进BMW，再进BMW，再入硬丝。

两三根PTCA导丝进入，就有慢慢扭开的可能了。

王琼（）：

可以送上去原来的导丝，按照靳主任的压住打折近段的导管，一边逆时针旋转，一边上送一点点导丝，一边轻轻回拉导管。

小东子-小武哥：

想象一下在平时如何解开打结的稍微硬一点的吸管，按住打结的远端，以防止远端转动，然后转动近端，稍微逆时针转动一圈，看看打的结是否松动，如果松动说明方向是对的。

滕继伟（唐都医院）：

压住导管近心端，尽量过一根导丝，准备圈套器。千万别使劲往下拽，防止损失血管内壁。

董鹏（航空总医院）：

相似的一个，我用股动脉上了抓捕器在头端抓住，两边固定再旋转拉直，能取出来。

小东子-小武哥：

把打结的吸管硬拉直，方法是好，如果结成疙瘩就不妙了！

王能（随州市中心医院）：

应该已经打开了，这个还好。

董鹏（航空总医院）：

不会，看着转，不至于。

王能（随州市中心医院）：

不会的，其实导管袢不好打开很大的原因就是旋转近端的时候袢的整体跟着动，只要远端固定住，绝大多数都是没问题的。

宋杰（南京鼓楼医院）：

解开了吗？实在不行可以从股动脉上圈套器拉住导管头端。

王能（随州市中心医院）：

可以用抓捕器。

宋杰（南京鼓楼医院）：

一般转一下可以解开的。

王涛（聊城市第二人民医院）：

用圈套器拉住导管头端，绿导丝尾端如能通过打折处可能还有希望。

孙甲强（河南宏力医院）：

最后把鞘管外导管剪断，穿刺股动脉，抓捕器拉至升主动脉，在大空间范围内，把折打开，从股动脉鞘管拉出。

唐世凡（武汉市三院）：

带导引导丝（冠脉导丝）进去慢慢地反方向旋转试试，有点太厉害了。

张道野（伊春市第一医院）：

放一小段逆旋的录影，帮你分析一下。都能打开，不要着急，抓捕器是一定行的，最好是把头端勾在颈动脉上松解。一定上泥鳅，三个结，中间的最厉害。转到试着通过。

刘鹏云（唐都医院）：

这个时候如何保证血管不痉挛也不容忽视。透视下送入钢丝或许有助于判断扭曲方向。

徐先进（安庆石化医院）：

听说过穿股动脉用抓捕器固定远端。

刘俭熊（珠海市人民医院）：

血压计袖带好用。

王鹏飞（新容奇医院）：

结放在肱动脉较宽处，压紧近心端，送入0.35绿色造影导丝，逆时针或顺时针旋转（向松解方向）同时顶导丝，基本都可解开。

尚云鹏（浙江大学医学院附属第一医院）：

这种上下有两个360度折的靠在手上转估计很难，是已经回撤过的吗？如果回撤过的估计得回到无名动脉，然后拿硬导丝顶着慢慢转，实在不行股动脉过去拉着前端扯一下直了再转。

马剑英（中山医院）：

股动脉送个导管抓捕器抓住导管头端再前向送入导丝透视下旋转看看。

王俊岭（252医院 ）：

一定要看清楚旋转的方向，反向旋转，轻轻上推，绝大多数都可松解，然后通过导丝撤出。导管打折预防最重要，看导丝的形态就应该有个预判，操作导管一定要看压力变化和导管头端的运动。早发现才好处理。

LI：

曾有相同病例，所有办法都不奏效，请外科医生处理，没透视，直接拔出来，加压包扎，没有并发症。导管打折拉到这个部位，圈套器已经抓不到远端。

李妍（唐都医院）：

好大的折！别着急，用手压住打折近端，全程透视下调整导管，看看哪个方向解环，同时一定要配合导丝，用泥鳅导丝好些。一边推进导丝，一边解环，如果解环过程中导管突出过大容易损伤血管，可以暂停解环，整体向近心端推一点，到达粗一点的血管段。

李春坚（南京医科大学第一附属医院）：

Transradial access is currently the most popular vascular access for cardiac catheterization since Lucien Campeau described it initially in 1989 [1,2]. It is widely accepted to be a very safe and viable approach, with significantlyless incidence of major access-related complications compared to the transfemoral approach. Most interventional cardiol-ogists prefer performing the procedure at the right side of the patient.since the right radial access is more convenient for manipulating catheters and devices.

In some cases, catheters can become entrapped looped/kinked during transradial catheterization in the brachial artery. Regular maneuvers and manipulations to disengage the catheter might be unsuccessful due tothe narrowdiameterof the artery. Wepresent two cases of coronary angiography complicated by right coronary catheter knotting and present a simple approach for their reduction in the brachial artery using the Amplatz GooseNeck Snare. Informed consents were obtained from both patients.

The first case was a 50-year-old woman with serious aortic valve stenosis who was transferred to the catheter lab for coronary angiography priortothe valvereplacement. Afterconsiderabletorquing of the Judkins right coronary catheter (JR3.5) (Cordis Europa, Roden, Holland), the right coronary artery was engaged and standard views were acquired. Upon withdrawal of the JR3.5 catheter, resistance was encountered and a knot was noted in the brachial artery.

The second case was a 71-year-old woman who was admitted for percutaneous coronary intervention due to exertional chest pain. Her subclavian and aorta vessels were noted to be very tortuous while the doctors were performing coronary artery angiography. On attempting intubation of the right coronary artery a knot was tied in the right brachial artery.

In the above cases the same technique was used when standard attempts failed to resolve the knot. On fluoroscopy, the catheter was found entrapped and kinked on itself in the brachial segment (Figs. 1A and 2A). The guidewire couldn't be able to pass through the knot, and applying clockwise or anticlockwise rotation or gentle.

Fig.1. A. Kinked and looped 6-Fr JR3.5 catheter in the right brachial artery. B. Snare in open position at the tip of the kinked JR3.5 catheter. C. Final successful unlooping of the JR3.5.

catheter with wire advancement before removal.

Fig. 2. A. Kinked and looped 6-Fr JR3.5 catheter in the right brachial artery. B. Snare in open position at the tip of the kinked JR3.5 catheter. C. Final successful unlooping of the JR3.5 catheter with wire advancement before removal. D. Coronary angiography showing significant lesions in LAD and LCX. E. Coronary angiography showing significant lesions in RCA. F.Coronary angiography after stenting showing TIMI 3 flow in LAD and LCX. G. Coronary angiography after stenting showing TIMI 3 flow in RCA.

traction couldn't reduce the knot. Attempts to unravel the catheter with gentle rotation caused severe forearm pain. Thus, the catheter could not withdraw from the brachial artery using the regular maneuvers.

The patients would undergo surgery if no effective method could solve the problem. However, we successfully retrieved the catheters by using the goose neck snare and the process was as follows. After right femoral artery puncture, a 6 French JR3.5 guiding catheter was used. Through the guiding catheter an Amplatz GooseNeck Snare (Microvena, St. Paul, MN) was passed and grasped the kinked catheter tip in the aorta arch. The entrapped catheter was then pulled simultaneously from the two ends under the help of the snare, and the looped catheter was straightened (Figs.1B and 2B). After releasing the snare (Figs. 1C and 2C), the kinked catheter was unraveled with a 0.35 inch guidewire and was successfully removed from the radial artery.

In Case 1, no stenosis was found in the coronary artery after angiography examination. Aortic valve replacement and ascending aortic valvuloplasty were performed successfully one week later. In Case 2, after removal of the catheter, angiography was completed by the right femoral approach and results showed occlusion of the left anterior descending artery (LAD) and severe stenosis in both the left circumflex artery (LCX) and right coronary artery (RCA) (Fig. 2D and 2E). Percutaneous coronary interventions of the LAD and LCX were successfully performed using 4 drug eluting stents (Fig. 2F). Four days later, RCA intervention was successfully performed by the radial approach (Fig. 2G). The patient was discharged 2 days later.

Minor looping of the coronary catheter is common during left heart catheterization and is usually the result of excessive torquing of the catheter, especially in a tortuous subclavian artery. It usually can be managed with gentle rotation in the opposite direction, and thus goes unnoticed without complications. Sometimes a guidewire can be advanced to the knot and with gentle traction of the catheter the wire may pass through and open the knot. However, more complex knots may rotate in the direction of torque adding further problems. This looped/kinked cathetercan getentrapped and may require surgery for retrieval. Furthermore, perforating the catheter is of risk if excessive force is used. A single case report has suggested that a second catheter through the contralateral femoral artery can facilitate manipulation of a kinked catheter [5]. The second catheter is passed alongside the knotted catheterand directedthrough the loop of the knot. The knot is then pulled back to the bifurcation of the aorta and moved gently to and fro enabling knot reduction. A further technique with W grabber device has also been described [6]. However, the above-mentioned techniques have their limitations in the form of dependence on

significant knot laxity and would therefore not be successful in the case of tighter knots. There is a great advantage of the technique that we have described. In the two cases we used the Amplatz GooseNeck Snare, which has the advantage of being open and can fixate the catheter from the side easily. Closed snares would require passing the device over the free end of the catheter. To the best of our knowledge, there is only one similar case described previously [7], where the authors used an Amplatz GooseNeck Snare to remove an entrapped catheter in the radial artery. In the case of tight catheter knots that do not respondtostandard maneuvers,wewould recommendthe useof this safe and easily applied technique, saving the patient from unplanned surgical intervention.

这是我发表在INT J CARDIOL的一篇文章，导管打折的一种处理办法，供参考。

周聪（南方医科大附属小榄医院）：

用到除了外科的最后一招，逆向套取，绝对行！看到孙主任说取出来了，像孙主任说的'最后把鞘管外导管剪断，穿刺股动脉，抓捕器拉至升主动脉，在大空间范围内，把折打开，从股动脉鞘管拉出。'既然套上拉到宽阔地方捋顺了，为啥不再送泥鳅导丝从原路返回？

徐浩（上海市第一人民医院）：

看导管近心端位置，如果在升主或者锁骨下，穿刺股动脉抓捕器固定近心端，慢慢打开后拉直。有一次打折，近心端在锁骨下，穿刺股动脉抓捕器到锁骨下，解开了，慢慢来，不能急。

林海龙（大连市中心医院）：

手压往往压不住，不知导管远端是否在主动脉弓里，如不在怎么转也没用，看能否将管再送到主动脉弓，再转。管在主动脉弓才能固定住远端。实在不行，只好下套圈了。

张涛（泊头市医院）：

多见于锁骨下及头臂干扭曲的病人。力臂变了，再者术者没有看压力曲线，一般打折前压力曲线就有表现了。反方向转直，拉出。

最后结果

穿刺左桡动脉用抓捕器，已成功退出，患者冠脉造影无异常。

今日阅读

本期编辑 | 张东伟 王敏 耿红静

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