Case Description. A 69-year-old female with hypertension and hyperlipidemia presented

Figure 1

Angiogram showing rigid and calcified proximal curvature, with large, obstructive filling defect (calcified plaque) in the mid-vessel of the right coronary artery. Note the small residual lumen on the inner aspect of the lesion in this projection.

with a 2-month history of worsening exertional angina. Nuclear perfusion imaging indicated ischemia in the inferior and inferoposterior walls, with preserved left ventricular function. Coronary angiography was notable for severely calcified vessels and a right dominant circulation. The left anterior

Figure 2

The distal aspect of the Venture™ catheter is visible as the radiopaque segment in the proximal vessel. With the tip pointed 90º inferiorly, the wire was successfully directed to the residual lumen and advanced across the lesion.

descending and left circumflex arteries were free of critical stenosis, but the right coronary artery was tortuous in its proximal segment, with a 99% mid-vessel lesion that appeared as a calcified, obstructive filling defect on orthogonal imaging (Figure 1).
       Coronary intervention proceeded utilizing a 7 Fr Left Amplatz 1.0 guiding catheter. Due to proximal curvature, the wire was repeatedly deflected away from the residual lumen despite multiple attempts with different conventional wires and balloon catheter backup. This included attempts with BMW (Guidant Corp., Indianapolis, Indiana), Asahi Soft (Abbott Laboratories, Abbott Park, Illinois), and ChoICE™ PT2 (Boston Scientific, Natick, Massachusetts) wires. It was determined that poor support and an inability to precisely direct the wire toward the residual lumen were precluding success. A final attempt was thus made using the Venture™ steerable wire control catheter (Velocimed, Minneapolis, Minnesota). The catheter was positioned at the proximal bend and directed 90 degrees inferiorly into the mid-vessel. This provided directability and pushability to allow a soft, hydrophilic wire to pass alongside the stenosis with minimal resistance. Figure 2 shows the coronary guidewire across the stenosis, with the Venture catheter seated in the proximal vessel. The wire passed freely to the distal vasculature, and the Venture catheter was removed. After exchanging for a rotational atherectomy extra support wire, multiple passes were made with a 1.5 mm burr. Serial balloon dilatations and 3.5 mm drug-eluting stent placement to the proximal and mid-vessel produced the final result (Figure 3). The patient was discharged without events the following day.

       Discussion. This case demonstrates successful coronary intervention of a tortuous and calcified lesion requiring the Venture steerable wire control catheter. This is the first description of an intervention utilizing this novel support catheter. The Venture is a 6 Fr compatible, single-use, over-the-wire support

Figure 3

Final result after rotational atherectomy and placement of two overlapping drug-eluting stents in the proximal and mid-vessel.

catheter with an 8 mm radiopaque deflectable tip (Figure 4). The tip may be deflected to any degree between 0 and 90, resulting in enhanced directability and support. This may prove beneficial not only in rigid and

Figure 4

Specifications of the Venture™ steerable wire control catheter.

tortuous vessels, but chronic occlusions and high-grade stenoses, angulated takeoffs, ostia of bifurcations and stent-jailed side branches as well. The over-the-wire design and low profile allow for wire exchange and delivery of drugs to the peripheral coronary circulation, though its use is restricted to long wires.
       Interventional cardiologists are being asked to perform angioplasty in increasingly complex lesion subsets. Indeed, 54% of intervened lesions are ACC/AHA Type B2 or C.¹ Despite improvements in operator technique and equipment, procedural failure still occurs in up to 10% and 20% of Type B2 and Type C lesions, respectively.^2,3 Failure is most commonly due to chronic occlusion or high-grade stenosis, vessel tortuosity or moderate-to-severe calcification.^2,4 The steerable wire control catheter allows directability and enhanced support, is compatible with all commercially available 0.014 inch long coronary guidewires, and can be used to improve procedural success in complex lesion and vessel morphology subsets.

1. Krone RJ, Shaw RE, Klein LW, et al. Evaluation of the American College of Cardiology/American Heart Association and the Society for Coronary Angiography and Interventions lesion classification system in the current “stent era” of coronary interventions (From the ACC-National Cardiovascular Data Registry). Am J Cardiol 2003;92:389–394.
2. Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic determinants of coronary angioplasty success and complications: Current experience. J Am Coll Cardiol 1995;25:855–865.
3. Krone RJ, Laskey WK, Johnson C, et al. A simplified lesion classification for predicting success and complications of coronary angioplasty. Am J Cardiol 2000;85:1179–1184.
4. Zaacks SM, Allen JE, Calvin JE, et al. Value of the American College of Cardiology/American Heart Association stenosis morphology classification for coronary interventions in the late 1990s. Am J Cardiol 1998;82:43–49.