Case report
Fracture of a guiding catheter in a tortuous iliac artery and its retrieval by a larger sheath
Fratura de um cateter guia numa artéria ilíaca tortuosa e a sua extração por uma bainha de maior calibre
Nuri Ilker Akkus
, Faisal Bahadur, Jai Varma
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LSU Health Sciences Center Shreveport, Division of Cardiovascular Diseases Shreveport, LA, United States
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=> 1667 "Tamanyo" => 289830 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Left: ICE image showing tenting of the interatrial septum (large white arrow) with the Mullins catheter and Brockenbrough needle (small white arrow). LA: left atrium; RA: right atrium. Right: ICE 2-chamber view after insertion of the ICE probe into the right ventricle (RV). Visualization of the mitral valve (white arrow) prior to percutaneous mitral balloon valvuloplasty. Left atrial enlargement and left ventricular function and dimensions can be assessed. (B) Percutaneous mitral balloon valvuloplasty. Angiographic and ICE visualization of the inflated Inoue balloon (white arrow). ICE catheter probe (large black arrow) is located in the RV and the pig-tail catheter (small black arrow) in the left ventricle. (C) Post-PMBV ICE assessment. Left: two-dimension assessment. Right: Doppler evaluation of the mitral valve showing 1+ mitral regurgitation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Konstantinos Marmagkiolis, Mehmet Cilingiroglu" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Konstantinos" "apellidos" => "Marmagkiolis" ] 1 => array:2 [ "nombre" => "Mehmet" "apellidos" => "Cilingiroglu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000322?idApp=UINPBA00004E" "url" => "/08702551/0000003200000004/v1_201308021344/S0870255113000322/v1_201308021344/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Fracture of a guiding catheter in a tortuous iliac artery and its retrieval by a larger sheath" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "341" "paginaFinal" => "344" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nuri Ilker Akkus, Faisal Bahadur, Jai Varma" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Nuri Ilker" "apellidos" => "Akkus" "email" => array:1 [ 0 => "iakkus@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Faisal" "apellidos" => "Bahadur" ] 2 => array:2 [ "nombre" => "Jai" "apellidos" => "Varma" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "LSU Health Sciences Center Shreveport, Division of Cardiovascular Diseases Shreveport, LA, United States" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Fratura de um cateter guia numa artéria ilíaca tortuosa e a sua extração por uma bainha de maior calibre" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 114423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fractured guiding catheter (black arrow) inside the 8F sheath (small black arrow). GC: guiding catheter; Kn: knot; Sh: sheath.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 51-year-old white man with a history of hypertension and tobacco abuse and a strong family history of premature coronary artery disease was initially admitted to our hospital with worsening chest pain and underwent pharmacological stress testing, which showed distal anterior and apical wall ischemia with preserved left ventricular systolic function. He was referred for coronary angiography, initially performed using a 6F system and right femoral artery access. A 95% lesion of the left anterior descending artery with thrombus was stented without complications. He continued to have chest pain and a second intervention via the left groin was performed four days later on a 80–90% stenosis of the mid right coronary artery (RCA) and 80% stenosis of the mid posterolateral ventricular branch (PLV). During the procedure a 0.035<span class="elsevierStyleHsp" style=""></span>inch wire and 6F sheath were advanced without difficulty. The RCA was engaged with a 6F Amplatz Left (AL) 0.75 guiding catheter (GC) (Cordis, Miami Lakes, FL) for better back-up and a 0.014<span class="elsevierStyleHsp" style=""></span>inch Balance Middle Weight (BMW) wire was advanced to the distal PLV without difficulty. Both lesions were predilated with a 3.0<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm compliant balloon and 3<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm Vision and 4.5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>mm Ultra stents were placed in the PLV and mid RCA, respectively, without difficulty and with an optimal result (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>). During the last cineangiogram, with the BMW wire inside the guide but outside the coronary artery, the AL GC became disengaged. We attempted to reengage the RCA but were unsuccessful, and could not transmit torque through the GC. Fluoroscopy revealed kinking of the distal GC in the external iliac artery. During attempts to straighten the GC by counterclockwise rotation, the guiding catheter fractured into two pieces (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The proximal broken piece came out with the sheath and manual pressure was applied. The BMW wire was still firmly attached to the guide. An 8F arterial sheath was then introduced partially up the broken GC over the BMW wire, the introducer sheath was removed, and attempts were made to advance a loop snare next to the kinked GC, with no success, and to advance a 0.035<span class="elsevierStyleHsp" style=""></span>inch J-tip wire next to the GC, also without success. At this time, the other option was to obtain access by the right femoral or brachial/radial artery to try to snare the proximal or distal end of the GC, but there were concerns because of the significant kink potentially traumatizing the exit vessel, especially with a brachial/radial approach. While we were considering advancing a 15-mm Amplatz gooseneck snare (ev3 Inc., Plymouth, MN) over the wire to snare out the distal fragment, it was decided to use the unusually firmly stuck BMW wire as an advantage and to pull back the wire while simultaneously advancing the 8F sheath over the GC. The BMW wire was pulled back rotating a hemostat in a counterclockwise direction and the sheath was advanced while clockwise rotation was applied, which enabled the GC to be straightened; we were able to withdraw the GC inside the sheath (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>), then the sheath was pulled out with the GC inside. Although the distal portion of the fractured GC was out, we were still unable to remove the BMW wire (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>); we therefore cut the guiding catheter proximal to the kink, removed the BMW wire and inserted a J-wire, removed the remaining GC and then reinserted the 8F sheath. The femoral angiogram showed tortuous iliac arteries with a small leak on the medial side of the sheath with no dissection or perforation (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>). A FemoStop was applied at low pressure to stop the leak around the sheath, and the sheath was then removed once active clotting time was <150<span class="elsevierStyleHsp" style=""></span>s. Hemostasis was achieved using manual pressure, and then a FemoStop was applied at low pressure for two more hours, followed by bed rest for a total of eight hours. The patient remained stable and asymptomatic throughout the procedure and overnight, and ambulated without difficulty the next day. The following day, before he was discharged, he went to the bathroom and had to strain, and subsequently developed acute left groin swelling and pain. Examination revealed a palpable hematoma suggestive of pseudoaneurysm. An ultrasound exam confirmed the existence of a 4.2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.9<span class="elsevierStyleHsp" style=""></span>cm pseudoaneurysm which was treated with ultrasound-guided compression. He was subsequently ambulating with no difficulty and was discharged home, and no new problems occurred during follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Ideally catheter material needs to be sufficiently stiff to maintain structural integrity but also to be sufficiently flexible to minimize discomfort or injury, which makes material selection very important. Catheters are made from polyvinyl chloride (PVC), polyethylene (PE), polyolefin copolymer (POC), or polyethylene terephthalate (PET). GCs are different from diagnostic catheters in that they are stiffer and have a larger lumen size. Their inner liner is a polytetrafluoroethylene coating with lubricating properties, the middle layer is braided stainless steel with stiffening properties, and the outer layer is a polymer (blended nylon).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Intravascular fracture of angiographic catheters is very rare and few incidents have been reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Kyriakides et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> reported reuse of catheters and polymer aging as the reasons for the four fractures they described. All of these six reported fractures were near the bond between the body and the catheter tip<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a>; four were diagnostic 7F or 8F Judkins right coronary catheters, one was a 4F diagnostic catheter and one was a 7F pigtail catheter. Schneider et al. reported an 8F diagnostic catheter fracture in the aortic arch and tested the tensile strength of Cordis 7F and USCI catheters. In their study, Cordis catheters have stable tensile strength for up to five years but deterioration was observed after seven years with deep cracks appearing in the lumen wall on microscopic examination.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Currently, Cordis catheters have three-year expiration dates and our GC had one more year before expiration.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Knotting of a coronary artery catheter at the level of the iliac arteries during coronary angiography is a recognized complication<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but there is no previous reported case of a GC fracture in the proximal shaft in the iliac artery. Knotting usually occurs as a result of excessive torquing mostly of the right coronary catheter when there is a tortuous iliac artery or aorta. When a knot formation is detected, simple maneuvers such as counterclockwise or clockwise rotation (depending on the last rotation applied to the catheter), or advancing the guidewire with gentle traction of the catheter and passing the wire through the knot, may reduce the knotting, but tighter knots may not resolve with such measures.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In such cases, after obtaining alternative distal access (contralateral femoral or radial), the proximal segment of the catheter above the knot can be snared with a loop snare to secure it and the proximal end of the catheter can be torqued clockwise or counterclockwise until the knot is reduced. This technique is usually effective in resolving these situations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Unfortunately, in our patient a slight counterclockwise rotation fractured the GC. Part of the reason for this could be the three knots in the GC visible after it was withdrawn (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>), suggesting multiple kink points in a highly tortuous iliac artery making multiple three-dimensional turns (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>). This was probably also the reason for the BMW wire entrapment.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once a catheter has fractured, snare-loop wires, nitinol goose-neck snares, or wire balloons<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> can be used percutaneously, but surgical intervention may be necessary. In our case, we were able to advance a larger (8F) sheath over the entrapped wire and successfully retrieved the remaining GC by simultaneously pushing the sheath and pulling the GC, applying opposite rotations which helped to straighten the knot and advance the sheath with less chance of vessel trauma. This technique can be used in fractured catheters with trapped wires.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">We describe a proximal GC shaft fracture in a patient with a tortuous iliac artery. Using a longer sheath and avoiding excessive manipulation would have prevented this complication in our patient. Once resistance is felt in torquing the catheters it is important to evaluate catheter shape at the level of the iliac arteries or aorta for knot formation before further manipulation. If there is catheter fracture with wire entrapment, advancing a larger sheath over the wire to capture the fractured segment can be considered for retrieval of this segment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical responsibilities</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres251127" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238724" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251126" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238723" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-04-14" "fechaAceptado" => "2012-07-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238724" "palabras" => array:2 [ 0 => "Fractured guiding catheter" 1 => "Tortuous iliac artery" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238723" "palabras" => array:2 [ 0 => "Fratura de cateter guia" 1 => "Artéria ilíaca tortuosa" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intravascular fracture of catheters, especially guiding catheters, is uncommon. We present an unusual case in which a guide twisted and broke in a tortuous iliac artery during manipulation of the guiding catheter with a 0.014<span class="elsevierStyleHsp" style=""></span>inch wire firmly trapped inside and was retrieved by a larger sheath.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A fratura intravascular de cateteres é pouco frequente, especialmente dos cateteres guia. Reportamos um caso inabitual em que o cateter guia foi torcido e lacerado numa artéria ilíaca durante a sua manipulação, estando o fio guia de 0,014″ no seu interior, e sua ulterior extração através de uma bainha de maior calibre.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 116492 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronary angiogram of the right coronary artery (RCA) showing 80% lesion of the mid-RCA and 90% lesion of the mid posterolateral ventricular branch (black arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 103524 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary angiogram of the right coronary artery showing optimal result after stent placements (black arrows).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 109409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Knotted, fractured guiding catheter with 0.014 inch wire inside, in the proximal external iliac artery. GC: guiding catheter; Kn: knot; GW: guidewire.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 114423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fractured guiding catheter (black arrow) inside the 8F sheath (small black arrow). GC: guiding catheter; Kn: knot; Sh: sheath.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 114563 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Angiogram of femoral artery with small leak (black arrow) and tortuous iliac artery (small black arrow).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1272 "Ancho" => 950 "Tamanyo" => 234292 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fractured guiding catheter (black arrow) with multiple knots and with the wire inside (small black arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SCAI Interventional Cardiology Board Review Book" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.J. Kern" 1 => "W. Laskey" 2 => "L. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2006" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catheter separation during cardiac catheterization and coronary angiography. A report of four incidents and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Z.S. Kyriakides" 1 => "I.P. Bellenis" 2 => "D.G. Caralis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Angiology" "fecha" => "1986" "volumen" => "37" "paginaInicial" => "762" "paginaFinal" => "765" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3767067" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful transradial retrieval of broken catheter fragment during transradial coronary angiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.H. Kim" 1 => "G.H. Kim" 2 => "K.W. Moon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Invasive Cardiol" "fecha" => "2012" "volumen" => "24" "paginaInicial" => "74" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22294538" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fracture of a polyurethane cardiac catheter in the aortic arch: a complication related to polymer aging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.M. Schneider" 1 => "R.E. Fornes" 2 => "W.C. Stuckey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cathet Cardiovasc Diagn" "fecha" => "1983" "volumen" => "9" "paginaInicial" => "197" "paginaFinal" => "207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6850832" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous technique for the reduction of knotted coronary catheters" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.A. Tanner" 1 => "D. Ward" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2003" "volumen" => "89" "paginaInicial" => "1132" "paginaFinal" => "1133" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12975396" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003200000004/v1_201308021344/S0870255113000450/v1_201308021344/en/main.assets" "Apartado" => array:4 [ "identificador" => "362" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000004/v1_201308021344/S0870255113000450/v1_201308021344/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000450?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 7 | 17 |
| 2024 Outubro | 63 | 34 | 97 |
| 2024 Setembro | 88 | 31 | 119 |
| 2024 Agosto | 76 | 29 | 105 |
| 2024 Julho | 55 | 39 | 94 |
| 2024 Junho | 55 | 29 | 84 |
| 2024 Maio | 68 | 24 | 92 |
| 2024 Abril | 55 | 42 | 97 |
| 2024 Maro | 51 | 27 | 78 |
| 2024 Fevereiro | 48 | 32 | 80 |
| 2024 Janeiro | 46 | 35 | 81 |
| 2023 Dezembro | 43 | 29 | 72 |
| 2023 Novembro | 48 | 18 | 66 |
| 2023 Outubro | 61 | 16 | 77 |
| 2023 Setembro | 53 | 15 | 68 |
| 2023 Agosto | 52 | 19 | 71 |
| 2023 Julho | 38 | 9 | 47 |
| 2023 Junho | 53 | 13 | 66 |
| 2023 Maio | 61 | 17 | 78 |
| 2023 Abril | 30 | 5 | 35 |
| 2023 Maro | 46 | 22 | 68 |
| 2023 Fevereiro | 37 | 20 | 57 |
| 2023 Janeiro | 37 | 19 | 56 |
| 2022 Dezembro | 47 | 28 | 75 |
| 2022 Novembro | 50 | 26 | 76 |
| 2022 Outubro | 56 | 25 | 81 |
| 2022 Setembro | 36 | 30 | 66 |
| 2022 Agosto | 52 | 26 | 78 |
| 2022 Julho | 53 | 41 | 94 |
| 2022 Junho | 49 | 30 | 79 |
| 2022 Maio | 41 | 38 | 79 |
| 2022 Abril | 45 | 28 | 73 |
| 2022 Maro | 31 | 38 | 69 |
| 2022 Fevereiro | 39 | 23 | 62 |
| 2022 Janeiro | 39 | 18 | 57 |
| 2021 Dezembro | 29 | 30 | 59 |
| 2021 Novembro | 32 | 48 | 80 |
| 2021 Outubro | 41 | 42 | 83 |
| 2021 Setembro | 41 | 34 | 75 |
| 2021 Agosto | 39 | 31 | 70 |
| 2021 Julho | 35 | 28 | 63 |
| 2021 Junho | 23 | 13 | 36 |
| 2021 Maio | 37 | 28 | 65 |
| 2021 Abril | 86 | 48 | 134 |
| 2021 Maro | 70 | 26 | 96 |
| 2021 Fevereiro | 116 | 12 | 128 |
| 2021 Janeiro | 44 | 10 | 54 |
| 2020 Dezembro | 58 | 6 | 64 |
| 2020 Novembro | 49 | 12 | 61 |
| 2020 Outubro | 52 | 17 | 69 |
| 2020 Setembro | 57 | 32 | 89 |
| 2020 Agosto | 40 | 17 | 57 |
| 2020 Julho | 42 | 16 | 58 |
| 2020 Junho | 56 | 9 | 65 |
| 2020 Maio | 65 | 7 | 72 |
| 2020 Abril | 38 | 11 | 49 |
| 2020 Maro | 55 | 8 | 63 |
| 2020 Fevereiro | 187 | 54 | 241 |
| 2020 Janeiro | 34 | 8 | 42 |
| 2019 Dezembro | 53 | 7 | 60 |
| 2019 Novembro | 44 | 10 | 54 |
| 2019 Outubro | 27 | 8 | 35 |
| 2019 Setembro | 29 | 16 | 45 |
| 2019 Agosto | 49 | 6 | 55 |
| 2019 Julho | 37 | 10 | 47 |
| 2019 Junho | 29 | 6 | 35 |
| 2019 Maio | 41 | 11 | 52 |
| 2019 Abril | 35 | 14 | 49 |
| 2019 Maro | 63 | 13 | 76 |
| 2019 Fevereiro | 43 | 15 | 58 |
| 2019 Janeiro | 88 | 5 | 93 |
| 2018 Dezembro | 55 | 11 | 66 |
| 2018 Novembro | 105 | 11 | 116 |
| 2018 Outubro | 161 | 16 | 177 |
| 2018 Setembro | 38 | 11 | 49 |
| 2018 Agosto | 46 | 12 | 58 |
| 2018 Julho | 43 | 7 | 50 |
| 2018 Junho | 44 | 8 | 52 |
| 2018 Maio | 50 | 9 | 59 |
| 2018 Abril | 53 | 11 | 64 |
| 2018 Maro | 63 | 10 | 73 |
| 2018 Fevereiro | 38 | 7 | 45 |
| 2018 Janeiro | 18 | 6 | 24 |
| 2017 Dezembro | 73 | 8 | 81 |
| 2017 Novembro | 36 | 15 | 51 |
| 2017 Outubro | 36 | 11 | 47 |
| 2017 Setembro | 53 | 14 | 67 |
| 2017 Agosto | 63 | 15 | 78 |
| 2017 Julho | 45 | 7 | 52 |
| 2017 Junho | 54 | 18 | 72 |
| 2017 Maio | 33 | 16 | 49 |
| 2017 Abril | 31 | 7 | 38 |
| 2017 Maro | 79 | 42 | 121 |
| 2017 Fevereiro | 108 | 19 | 127 |
| 2017 Janeiro | 28 | 9 | 37 |
| 2016 Dezembro | 32 | 11 | 43 |
| 2016 Novembro | 33 | 12 | 45 |
| 2016 Outubro | 60 | 11 | 71 |
| 2016 Setembro | 66 | 14 | 80 |
| 2016 Agosto | 20 | 4 | 24 |
| 2016 Julho | 14 | 11 | 25 |
| 2016 Junho | 7 | 12 | 19 |
| 2016 Maio | 19 | 0 | 19 |
| 2016 Abril | 49 | 5 | 54 |
| 2016 Maro | 91 | 16 | 107 |
| 2016 Fevereiro | 97 | 26 | 123 |
| 2016 Janeiro | 98 | 12 | 110 |
| 2015 Dezembro | 78 | 12 | 90 |
| 2015 Novembro | 78 | 7 | 85 |
| 2015 Outubro | 88 | 13 | 101 |
| 2015 Setembro | 85 | 11 | 96 |
| 2015 Agosto | 99 | 15 | 114 |
| 2015 Julho | 128 | 6 | 134 |
| 2015 Junho | 60 | 1 | 61 |
| 2015 Maio | 75 | 7 | 82 |
| 2015 Abril | 68 | 15 | 83 |
| 2015 Maro | 81 | 5 | 86 |
| 2015 Fevereiro | 73 | 5 | 78 |
| 2015 Janeiro | 74 | 9 | 83 |
| 2014 Dezembro | 72 | 15 | 87 |
| 2014 Novembro | 90 | 8 | 98 |
| 2014 Outubro | 99 | 14 | 113 |
| 2014 Setembro | 70 | 10 | 80 |
| 2014 Agosto | 69 | 11 | 80 |
| 2014 Julho | 88 | 10 | 98 |
| 2014 Junho | 106 | 6 | 112 |
| 2014 Maio | 93 | 13 | 106 |
| 2014 Abril | 61 | 8 | 69 |
| 2014 Maro | 104 | 18 | 122 |
| 2014 Fevereiro | 108 | 10 | 118 |
| 2014 Janeiro | 107 | 18 | 125 |
| 2013 Dezembro | 69 | 17 | 86 |
| 2013 Novembro | 73 | 16 | 89 |
| 2013 Outubro | 86 | 10 | 96 |
| 2013 Setembro | 77 | 25 | 102 |
| 2013 Agosto | 77 | 22 | 99 |
| 2013 Julho | 90 | 25 | 115 |
| 2013 Junho | 86 | 22 | 108 |
| 2013 Maio | 112 | 37 | 149 |
| 2013 Abril | 20 | 16 | 36 |
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