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\begin{document}

\title{Balloon internal fixation- a novel approach to manipulate catheter knot}



\author[1]{xianliang Yan}%
\author[2]{Tao Sun}%
\affil[1]{Capital Medical University}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\begin{abstract}
Trans-radial approach (TRA) is nowdays a more common approach during
percutaneous coronary angiography and intervention. Catheter knot is
rare but still a matter of concern for a catheterizing cardiologist.
Hence, we describe our case of catheter unknotting using balloon
internal fixation of angiography catheter.%
\end{abstract}%



\sloppy


\textbf{Balloon internal fixation- a novel approach to manipulate
catheter knot}

\textbf{Abstract:} Trans-radial approach (TRA) is nowdays a more common
approach during percutaneous coronary angiography and intervention.
Catheter knot is rare but still a matter of concern for a catheterizing
cardiologist. Hence, we describe our case of catheter unknotting using
balloon internal fixation of angiography catheter.

\textbf{Keywords} Trans-radial access; catheter knot; balloon internal
fixation

\textbf{Introduction}

TRA has become the first choice for coronary intervention, with few
complications and more comfortable for patients \textsuperscript{{[}1,
2{]}}. However, this novel access may lead to severe catheter twisting
and following manipulation may be required to unravel the catheter and
to avoid complications\textsuperscript{{[}3{]}}. Re-rotate catheter can
handle minor problems, but there were also some cases so severe that
can't be handled by this method but surgical intervention. In this
report, we describe our technique to handle catheter knot and report its
short-term outcome.

\textbf{CASE PRESENTATION}

A 62-year-old woman with history of hypertension underwent selective
coronary angiography because of intermittent chest pain for 10 days. The
right radial artery was the access of choice. After easy cannulation, 5
French multifunctional angiography catheter (Terumo Corporation) was
introduced into aortic sinus. Initially, subclavian tortuous anatomy
made catheter rotation redundancy, and then the pressure curve was
partial dampening, and with fluoroscopy it revealed an outright knot
within right brachial artery (Fig 1). Gentle traction or rotation did
not allow catheter withdrawal. We decided to untwist the catheter knot
by balloon internal fixation and the details were as follows: Cut off
the tail of discounted catheter and the tip of 6 French EBU3.5 guiding
catheter (Medtronic). A 2.0\selectlanguage{ngerman}×20mm balloon(Sprinter legend\selectlanguage{english},Medtronic)
passed through the cut guiding catheter from tail to tip(Fig 2) and then
passed through the cut angiography catheter(Fig 3). When the balloon all
passed through the cut angiography catheter, the balloon was given
atmospheric pressure of about 14 atm and make sure that the balloon and
the angiography catheter contact tightly (Fig 4). The guiding catheter
was pushed to the knot point along angiography catheter by left hand.
The balloon was pulled out gently under fluoroscopy and the knotted
catheter was pulled out successfully (Fig 5). During the whole traction
period, there was no discomfort of patient and the tip of angiography
catheter was complete. Contrast was injected from the sheath to confirm
patency of the brachial artery. After 10 days' follow up, there was no
discomfort in right upper limb of the patient.

\textbf{Discussion}

There are many reasons that make angiography catheter discount,
including vascular tortuosity,

vasospasm, abnormal ostial of coronary artery, unskilled manipulation,
excessive traction and rotation. Understanding the tortuosity of blood
vessels in advance, and avoiding excessive rotation of the catheter,
maintaining a guide wire in the catheter lumen can help us to prevent
catheter from looping.

Once the catheter was knotted, inadequate manipulation and excessive
traction can make catheter fracture or even artery
dissection\textsuperscript{{[}4, 5{]}}. There were several methods to
retrieve catheter knot, such as gentle rotation of the catheter to the
opposite direction, advancement of a super stiff wire into the loop,
external fixation of the distal part of the catheter at the arm level
with a blood pressure cuff\textsuperscript{{[}6{]}}, snare
delivery\textsuperscript{{[}7-9{]}}. In catheter ablation procedure,
steerable sheath was also used to untie diagnostic decapolar catheter
knot\textsuperscript{{[}10{]}}.

When it was difficult to withdraw the knotted catheter, we can advance a
bigger cut guiding catheter outside the angiography catheter to
strengthen the supporting power and exchange the shape of angiography
catheter. Pushing the guiding catheter into the knot point and pulling
the angiography catheter gently at the same time can help us to withdraw
the knotted catheter. In our case, the internal diameter of 6 French EBU
guiding catheter was 1.8mm, which was bigger than the external diameter
of 5 French angiography catheter, which was 1.7mm, and make sure that
the guiding catheter can enclose the angiography catheter. According to
Aminian's study\textsuperscript{{[}11{]}}, the length of guiding
catheter was between ``Knotted point- Puncture point'' distance and
``Knotted point- Cut point'' distance, and the length of
exceeded-guiding catheter part of angiography catheter was too short to
fix, so that we make balloon and angiography catheter contact tightly
and as a result we prolong the length of exceeded-guiding catheter part
of angiography catheter sufficiently in order to facilitate the
procedure, which was a bright point of our case.

\textbf{Conclusion}

The method of balloon internal fixation of angiography catheter was
simple, practical and economical, and this method can reduce artery
injury also can avoid surgery. It provided us a new method and choice to
handle catheter knot.

\textbf{FUNDING SOURCE}

This article did not receive any specific grant from funding.

\textbf{CONFLICT OF INTEREST}

We report no competing interest associated with the work reported in
this manuscript.

\textbf{References}

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