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We report a case of severe radial artery vasospasm and catheter entrapment during ipsilateral subclavian artery stenting that was refractory to all treatment. A supraclavicular nerve block resulted in vasodilation and release of the catheter, facilitating its removal.
A 64-year-old woman with critical left subclavian stenosis (>95%) presented for a cerebral angiogram, angioplasty with intravascular lithotripsy, and subsequent stenting. During general anesthesia, a 7F left radial artery sheath was placed and a stent was deployed. The sheath could not be removed after the procedure. Angiography revealed radial artery vasospasm, entrapping the catheter, with complete obliteration of distal blood flow to the level of the brachial artery (Fig 1). Warm compresses, topical, subcutaneous, and intraarterial nitroglycerin, verapamil, and catheter lubricant injectate failed to reverse the vasospasm. Reactive hyperemia also was attempted by inflating a blood pressure cuff on the affected arm for 2 minutes followed by release of the cuff. Despite all these measures, catheter entrapment and restoration of distal blood flow could not be corrected. The regional anesthesia team was consulted to attempt a sympathetic nerve block. An ultrasound-guided supraclavicular block with 1% lidocaine (30 mL) was performed. The catheter was then successfully removed from the left upper extremity with the restoration of blood flow. (Fig 1)
Catheter entrapment from arterial vasospasm during an endovascular procedure is a rare but serious complication that may require vascular surgery for removal and revascularization if not corrected by other means. The use of a brachial plexus nerve block for the management of catheter entrapment is limited, but this technique is recommended as a third-line treatment when other therapies have failed .
Theoretically, stellate ganglion block also may achieve similar results; but, to our knowledge, has not been attempted.
Conflict of Interest
Dr. Ajit S Puri has the following conflicts of interest: he is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q'Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical; has received research grants from National Institues of Health, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular; and is a stock holder in InNeuroCo, Agile, Perfuze, Galaxy, and NTI.
Transradial vs. transfemoral Approach in cardiac catheterization: A literature review.