Editor’s Note: “This case further highlights the difficulty we can face in some complex cases and its solution by providing extra back-up support using the GuideLiner catheter. Clearly, the GuideLiner should be reserved for challenging cases requiring extra back-up support." — Samin K. Sharma, MD, Mount Sinai Medical Center, New York, New York
Despite current improvements in delivery systems, failure to deliver stents still occurs in up to 5% of percutaneous coronary interventions (PCI),1 particularly in tortuous or heavily calcified arteries. Newer generations of stents are characterized by high longitudinal flexibility and low profile, however, crossing a severely tortuous segment still represents a challenge. In addition, in complex coronary interventions, particularly chronic total occlusion (CTO) interventions, guiding catheter back-up is of paramount importance to allow advancing a wire or balloon across the CTO, hence the frequent need for large guides, guides with opposite aortic wall contact and deep-seating maneuvers to provide support.
We describe a case of a complex bifurcational native left anterior descending artery (LAD) CTO treated through a tortuous venous graft with the support of a new device, the GuideLiner (Vascular Solutions, Inc., Minneapolis, Minnesota). To our knowledge, this is the first reported use of the GuideLiner for treatment of a complex native coronary artery stenosis through a graft.
Case Report. A 70-year-old man presented with severe exertional angina that had been progressive for the previous 3 months. He had a history of 2 prior coronary artery bypass graft surgeries, the last one 22 years prior to presentation. A coronary angiogram performed at an outside facility revealed severe three-vessel native coronary artery disease with a totally occluded LAD past the first septal and diagonal branches, and a composite Y saphenous venous graft (SVG) that had a single origin and three limbs with three distal anastomoses (mid-LAD, obtuse marginal branch and distal right coronary artery) (Figure 1). The anastomosis of the venous graft with the LAD had a 75% stenosis, and the LAD had a total occlusion immediately past the anastomosis with a thrombolysis in myocardial infarction (TIMI) 2 distal flow. His left ventricular function was normal. Percutaneous therapy of the LAD occlusion was attempted at the outside facility, but delivery of a guidewire and a support catheter through the SVG bends was not successful (a 6 Fr Judkins right 4 guide was used to engage the graft). The patient was placed on medical therapy then referred to us 3 months later for PCI. We accessed the right femoral artery, then engaged the SVG with a 7 Fr Judkins right 4 guide (after failure of our attempt to engage the SVG with an Amplatz left 1 guide). We advanced a GuideLiner catheter 5 cm beyond the SVG ostium up to the first SVG loop (Figure 2). We then unsuccessfully attempted to cross the CTO of the LAD using a PT Graphix wire (Boston Scientific Corp., Natick, Massachusetts) and the additional support of a FineCross catheter (Terumo, Japan) advanced distally in the SVG. Further attempts were performed using Whisper (Abbott Vascular, Abbott Park, Illinois), Confianza (Abbott Vascular) and PT 2 (Boston Scientific) wires, with no success (Figure 2). Subsequently, we decided to wire the retrograde segment of the LAD through the SVG and we treated the anastomotic lesion with a 3 x 6 mm cutting balloon, then with a 3.5 x 12 mm Promus® stent (Boston Scientific) extending from the SVG retrogradely into the mid LAD (Figure 3). Afterward, the flow significantly worsened in the distal LAD (TIMI 1 flow). At this point, we reattempted wiring the CTO using a PT 2 wire and were immediately successful, probably because of the modification of the CTO cap and angulation after adjacent stenting. The LAD was antegradely stented with a 2.75 x 20 mm Promus stent that extended into the SVG (the two stents overlapped in a culotte fashion) (Figure 4). Post-stent dilatation was performed with a high-pressure balloon. The final angiogram showed excellent flow in the LAD both antegradely and retrogradely (Figure 5).
Discussion. Guide support is critical in complex intervention and is improved by selection of larger guides (e.g., 7 Fr), coaxial guides, guides with a large contact area on the opposite aortic wall and by the deep-seating maneuver. Several other techniques have been used to improve guide support in tortuous lesions and in CTO interventions.2 These include guide stabilization by wire anchoring, wherein a stiffer wire is advanced in a proximal side-branch; guide stabilization by balloon anchoring, wherein a small 1.5 mm balloon is inserted in a small proximal branch or in the distal main vessel and inflated at low pressure, therefore preventing the guide from backing out. However, these techniques have caveats. Deep-seating may damage the coronary ostium and lead to ostial dissection or late ostial stenosis, while the anchoring techniques may lead to side-branch endothelial damage. In addition, difficulty in advancing a stent may be encountered in tortuous and in calcified or diffusely diseased arteries. Several technical manipulations have been described to allow stent delivery:3,4
- Optimization of guide support as described above;
- Buddy-wire technique with a stiffer wire that allows guide stabilization but also straightens the arterial segment proximal to the lesion and allows less friction during stent delivery;
- Treatment of a proximal calcified or rough plaque resistive to stent passage;
- Changing the stent to a shorter stent or to a more flexible brand of stent.
These techniques may, however, fail. Our case illustrates the efficacy of the GuideLiner catheter in providing the support needed for crossing a CTO and for stent delivery in challenging cases. We used it up front due to previous failure in advancing a guidewire and a support catheter through the SVG. The GuideLiner is a flexible catheter that is 1 French size smaller than the guide catheter and that is delivered through the guide. It has a rapid-exchange design and is advanced over standard-length guidewires, with a monorail length of 20 cm and a working length of 135 cm (Figure 6). The GuideLiner extends beyond the guiding catheter and is seated deeply in the coronary artery, allowing support and coaxial alignment for advancement of guidewires, balloons and stents during coronary interventions. It also allows coaxial alignment when an unusual coronary ostium takeoff prevents appropriate guide engagement. While the extension is 20 cm long, a maximum extension of only 10 cm beyond the guide tip is recommended and has a silicone coating for lubricity. The GuideLiner is available in three sizes (Table 1): 6 Fr (5 Fr GuideLiner that goes inside a 6 Fr guide, therefore called “5-in-6” system), 7 Fr and 8 Fr. Most devices and coronary stents will fit through a 5-in-6 system. In light of its size, the GuideLiner is contraindicated in vessels that are
The flexible and soft design of the GuideLiner allows atraumatic extra-deep intubation of the native coronary arteries and of arterial and venous bypass grafts, and is theoretically associated with a low risk of coronary injury in comparison to deep-seating of the guiding catheter. In fact, it has no primary curve to potentially damage and dissect the vessel. Moreover, it has a coil backbone that provides superior flexibility while retaining radial strength, and it can be seated much deeper than the guiding catheter. This allows advancement of a device through a tortuous or angulated or calcified proximal segment without getting exposed to friction with the vessel wall. One in-vitro experiment has shown that a 5 Fr catheter protruding by 5 mm into an arterial experimental system provided more backup than a 7 Fr guide catheter system.5 Few reports have previously documented the efficacy and safety of the use of a “5-in-6” system in cases of tortuous or heavily calcified vessels or CTOs.6–8 The initial 5-in-6 system consisted of an over-the-wire 5 Fr catheter (Heartrail II, Terumo), but the current rapid-exchange design of GuideLiner is easier to use and allows delivery through the preexisting Y-adapter without limiting the effective length of devices used in the intervention.
Conclusion. We report the first case of GuideLiner use in complex native coronary artery intervention through a venous graft. The atraumatic deep-seating allowed by this device provided the extra support needed to cross a CTO beyond tortuous segments and to advance devices through sharp angulations. In addition, its monorail design allowed its easy advancement through the hemostatic valve and easy handling of balloons and stents.
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- Takahashi S, Saito S, Tanaka S, et al. New method to increase a backup support of a 6 French guiding coronary catheter. Catheter Cardiovasc Interv 2004;63:452–456.
- Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the Heartrail III catheter as a stent delivery catheter following failure of conventional techniques. Catheter Cardiovasc Interv 2008;71: 358–363.
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- Mamas MA, Eichlofer J, Hendry C, et al. Use of Heartrail II catheter as a distal stent delivery device; An extended case series. Eurointervent 2009;5:265–271.