Double-Catheter Technique for Catheterization of the Left Coronary Artery in a Patient with an Ascending Aorta Aneurysm

Josef Veselka, MD, PhD, FESC, FSCAI and David Zem√°nek, MD
Josef Veselka, MD, PhD, FESC, FSCAI and David Zem√°nek, MD
Aneurysms of the ascending aorta are not uncommon in the catheterization laboratory. When encountered, they lead to problems catheterizing the left coronary artery in particular. We typically use catheters with a large bend in these cases (Amplatz Left 3.0 or Judkins Left 6.0). However, in cases with an extremely dilated ascending aorta, it is impossible to reach the ostium of the left coronary artery by standard diagnostic catheters. Prior reports described an antegrade (transseptal) approach when the conventional retrograde approach was not possible.1,2 Because transseptal catheterization is not performed on a routine basis at our institution, we elected to perform coronary angiography using a retrograde double-catheter technique. Case report. An 82-year-old woman was admitted for dyspnea and possible acute coronary syndrome. She was referred for urgent coronary angiography. The right coronary artery was of normal appearance. An extremely dilated ascending aorta did not allow us to reach the ostium of the left coronary artery using standard large diagnostic catheters (Judkins Left 6.0 and Amplatz Left 3.0). Aortography revealed an aneurysm of the ascending aorta (9 cm diameter) with mild aortic regurgitation (Figure 1). A 7 Fr guiding catheter (Amplatz Left 2.0, Cordis Corp., Miami, Florida) was advanced into the aortic root and a multipurpose diagnostic catheter (4 Fr, 125 cm long, Cordis) was passed through the guiding catheter using a Y connector. Since the multipurpose catheter was longer than the guiding catheter, we reached the ostium of the left coronary artery and the angiography was successfully completed (Figures 2 and 3). The left coronary artery was of a normal appearance as well. Cardiac surgeons were consulted to treat the aortic aneurysm. Discussion. The double-catheter technique (“coaxial technique”) was described for the diagnostic catheterization of peripheral arteries, coronary arteries and percutaneous interventions.3,4 It allows for improvement of catheter back-up as well as the extension of the catheter system in cases with a dilated aorta. As far as we are aware, this is the second case describing this technique in a patient with a dilated ascending aorta. Based on the literature and our experience, we can recommend this simple technique of coronary angiography in patients with an extremely dilated ascending aorta.
1. Farah B, Prendergast B, Garbarz E, et al. Antegrade transseptal coronary angiography: An alternative technique in severe vascular disease. Cathet Cardiovasc Diagn 1998;43:444–446. 2. Pearce A, Schwengel R, Simione L, et al. Antegrade selective coronary angiography via transseptal approach in a patient with severe vascular disease. Cathet Cardiovasc Diagn 1992;26:300–303. 3. Geijer H, Kahari A. Coaxial technique for catheterization of the coronary arteries with a very dilated ascending aorta. Catheter Cardiovasc Interv 2004;62:32–34. 4. Sharma S, Mahapatra M, Bhargava S, et al. Utility of coaxial technique for renal angioplasty in patients with a difficult-to-cross stenosis. Eur Radiol 1999;9:1586–1589.