A 59-year-old woman with late onset ST-elevation myocardial infarction (STEMI) was admitted for Percutaneous Coronary Intervention (PCI). On admission, patient complained of epigastric pain and dyspnea on exertion since a day ago. Physical examination revealed clear lung sound on auscultation and no murmur was heard. Her blood pressure was 169/75 mmHg, heart rate 65 beats/minute, oxygen saturation 98% in room air, respiratory rate 20 breaths per minute, and temperature was 36.5 °C.

Electrocardiogram (ECG) showed Q waves and ST elevation in lead II, III, aVF.  Her laboratory investigation revealed hemoglobin 13.2 g %, total leucocyte counts 10.710 cells/mm3, and platelets 244.000 cells/mm3. The cardiac markers Troponin I was significantly elevated 74.71 ng/ml. Her random blood sugar (RBS) was 161 mg/dl, and creatinine 0.89 mg/dl. Electrolyte was within normal limit. Chest X Ray showed normal heart and lung findings.

LM: non significant stenosis LAD: moderate stenosis at osteal and mid part of LADLCX: mild to moderate stenosisRCA: total occlusion at proximal part

We did diagnostic angiography from right radial artery using IL 6F. LCA showed non-significant stenosis at Left Main, mild to moderate stenosis at LAD and LCX. RCA showed total occlusion at proximal part. Patient was planned for PCI using the same guiding catheter but unfortunately the catheter was disengaged from RCA ostium. Clockwise and anti-clockwise maneuver was unsuccessful, and we realized that the catheter was twisted at brachial artery (figure 1). Some maneuver was done by pulling and rotating to untwist the catheter but unsuccessful. Additional access was done at the right femoral artery. 6F JR guiding was advanced to right subclavian artery. Snare catheter was used in attempt to anchor the radial catheter from the distal end but failed. We tried wiring the twisted catheter from femoral guiding using coronary wire. Semi compliant balloon was advanced from femoral guiding catheter and inflated with high pressure at distal end of radial catheter. Both catheters were pulled until kiss each other (kissing-catheter, figure 2).  Femoral guiding was pulled from femoral site with some traction and twisted catheter was rotated clockwise and anti-clockwise until both knots released (figure 3). Released catheter retrieved from radial sheath. We proceeded to treat the total occluded RCA via the same femoral access. PCI was performed with 1 DES implantation at proximal RCA. Final angiography showed minimal dissection at brachial artery without limiting the flow to distal. 

PCI procedure could also rise some complications and sometimes take us by surprise, like our case that described above. Caution is important when doing a catheter manipulation, especially when some resistance felt. We should not be panic over the unpredicted complication. We should decide precise methods and took steps wisely according to the patient’s condition.