To the Editor:

Percutaneous coronary interventions of thrombotic or friable lesions, such as in acute myocardial infarctions, can often result in distal embolization. To circumvent this problem, modern techniques frequently involve pretreatment with thrombectomy devices. The Pronto™ (Vascular Solutions, Inc., Minneapolis, Minnesota) and Export^® (Medtronic, Inc., Minneapolis, Minnesota) catheters feature dual-lumen platforms consisting of a central rapid exchange wire lumen as well as an eccentric aspiration lumen. They are designed for rapid, manual syringe aspiration of thrombus as well as friable atherosclerotic debris. We have found them, however, to be useful in other aspects of percutaneous intervention.
In such lesions, we have routinely advanced these catheters beyond the stenoses and administered intracoronary nitroprusside and/or adenosine via the aspiration lumen prior to performing aspiration. Repeated, gentle distal-to-proximal as well as proximal-to-distal manual aspiration runs are then performed. By using pharmacologic “pre-pretreatment”, we have encountered no incidences of slow-reflow or no-reflow, which can occasionally be seen with any of the aspiration devices. Although we have not needed to do so, post-aspiration injections can certainly be performed in the same manner. In contrast to the usual technique of injecting these agents through a balloon or single-lumen catheter such as the Transit™ catheter (Cordis Corp., Miami, Florida), simultaneous wire position is maintained via the rapid exchange lumen.
Additionally, wire exchange, when required for improved support through tortuous anatomies, is easily accomplished by inserting the second wire through the aspiration lumen. Either a short or long initial wire, which remains in the rapid exchange lumen, can be easily exchanged for a stiffer one. Again, unlike the situation with the single-lumen catheters, the primary wire is removed only after the secondary wire is advanced distally. The former serves as a roadmap of the distal vasculature beyond the catheter tip. Alternatively, by leaving in the primary wire, the “buddy wire”, “parallel wire”, or “see-saw” techniques (the latter two mainly used for chronic total occlusions)¹ are readily accomplished.
When using the “buddy wire” technique to recross a deployed stent, occasionally these higher-profile dual-lumen catheters cannot be advanced through the stent. In these circumstances the distal catheter tip is placed at the proximal stent edge. We then shape an exaggerated loop on the distal end of the second wire and insert it into the aspiration lumen using a wire introducer. Once the tip of this wire has exited the distal aspiration opening, it loops in the stent and is easily advanced distally without concern of passage beneath struts. Alternatively, if initial wire position distal to the stent has been lost and difficulty is encountered in re-crossing, this technique can be similarly used by leaving the initial wire at the proximal stent edge and advancing the catheter to the same location.
Although subtle differences exist between these two products, in our experience, they have been interchangeable. The Pronto catheter has a proprietary atraumatic tip as well as a slightly larger aspiration opening and stiffer shaft, which may decrease the incidence of kinking. Thus these simple, relatively inexpensive yet practical platforms offer the operator multiple options for the treatment of complicated coronary lesions, without the need for multiple devices.

Jack P. Chen, MD
Northside Cardiology, P.C.
Atlanta, Georgia
E-mail: chenjackapollo@yahoo.com