Coronary Guidewire Research Articles

AS-198: Pulmonary Atresia with Intact Septum: Use of Conquest Pro Coronary Guidewire for Perforation of Atretic Valve and Subsequent Interventions

Radiofrequency valvotomy (RFV) and balloon dilatation has become the standard of care for pulmonary atresia with intact ventricular septum (PAIVS) in many institutions today. The objective of the study was to determine the feasibility and safety of the Conquest Pro wire as an alternative to Radiofrequency (RF) wire for perforation of atretic pulmonary valve and subsequent balloon dilatation ± patent ductus arteriosus stenting in patients with PAIVS.

Alternative method for accessing the target coronary artery in patients with difficult coronary anatomy: exchanging the diagnostic catheter with a guiding catheter

We report a method of the placement of the guiding catheter in two cases in which the diagnostic catheter could be easily engaged to the target coronary arteries but not a guiding catheter, due to a distorted aortic sinus and an osteal subtotal occlusion, respectively. After engaging to the target coronary artery with a diagnostic catheter, a coronary guidewire was advanced through the diagnostic catheter, and exchanged with a guiding catheter over the guidewires. The procedures were completed with success.

Fractional flow reserve-guided ‘spot stenting’ in intermediate coronary stenosis—a case report

Correspondence: Dr. Aniket Puri, Associate Professor, Department of Cardiology, CSM Medical University, Lucknow, UP. E-mail: aniketpuri@hotmail.com Fractional flow reserve is an index of the physiological significance of a coronary stenosis and is defined as the ratio of maximal blood flow in a stenotic artery to normal maximal flow.4 It can be measured during coronary angiography by calculating the ratio of distal coronary pressure measured with a coronary pressure guidewire to aortic pressure measured simultaneously with the guiding catheter. FFR in a normal coronary artery equals 1.0. The information provided by FFR is similar to that obtained with myocardial perfusion studies, but it is more specific and has a better spatial resolution, because every artery or segment is analyzed separately, and masking of one ischemic area by another, more severely ischemic, zone is avoided.5,6 Deferring percutaneous coronary intervention (PCI) in nonischemic stenotic lesions, as assessed by FFR, is associated with very low annual rate of death or MI, as was seen in DEFER trial patients,2 whereas deferring PCI in lesions with an FFR of 90%.4,7,8 The recent data from recent FAME9 trial has shown that 0.80 is more accurate value to identify truly ischemic lesions. Retrospective studies suggest that in patients with multivessel coronary artery disease, FFRguided PCI is associated with a favorable outcome with respect to event-free survival.10 We report a case of FFR-guided PCI, which highlights the importance of assessment of functional significance and its contribution in proper clinical decision making.

Endovascular Treatment of Diabetic Foot Syndrome: Results from a Single Center Prospective Registry Using Mixed Coronary and Peripheral Techniques and Equipment

To assess the long-term results of interventional treatment of diabetic foot using mixed coronary and peripheral equipments and techniques. The interventional diabetic foot syndrome treatment is rapidly becoming the therapy of choice in such patients, but proper materials and techniques are still debated. From January 2006 to December 2010, we prospectively enrolled 220 diabetic patients (78.5 ± 15.8 years, 107 females, all with Fontaine III or IV class), referred to our center for diabetic foot syndrome and severe limb ischemia. Mixed coronary and peripheral guidewires and balloons techniques were used. Doppler ultrasonography and foot transcutaneous oxygen pressure (TCPO2) before and after the procedure were calculated as well as the amputation rate. The preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%), contralateral cross-over in 40/220 patients (18.8%), and popliteal retrograde + femoral antegrade in 10/220 patients (4.5%). The techniques included combined use of coronary and dedicated peripheral guidewires and coronary and peripheral dedicated balloons. Balloon angioplasty was performed in 252 legs (32 patients with bilateral disease): the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TCPO2 and ankle-brachial index with ulcer healing in 233/252 legs (92.4%). The freedom from major amputation was 82.8% at a mean follow-up of 3.1 ± 1.8 years (range 1 to 5 years). The endovascular diabetic foot syndrome treatment using mixed coronary and peripheral materials and techniques seems to lead to high immediate success and limb salvage rates compared to historical series.

A Complex Case of Angulated and Bifurcated Lesion Facilitated by Excimer Laser Coronary Angioplasty

Angulated lesions have been shown to be associated with abrupt closure or periprocedural myocardial injury. In particular, when disease is present at the level of the angulated or bifurcated lesion, balloon dilatation may help in wire crossing but it may also cause branch occlusion. Several methods and devices have been described to manipulate coronary guidewires across angulated and bifurcated lesions. This case report describes a highly angulated coronary bifurcated lesion where, after the failure of multiple wires to cross the lesion toward the main branch, it was successfully crossed after excimer laser debulking, which facilitated the wire crossing into the main branch, without causing branch occlusion.

First-in-Human Evaluation of a Novel Robotic-Assisted Coronary Angioplasty System

We aimed to evaluate the safety and feasibility of a robotic angioplasty system in delivery and manipulation of coronary guidewires, balloons, and stents in patients undergoing elective percutaneous coronary intervention (PCI). A remote-control, robotic-assisted angioplasty system is under development to address some of the procedural challenges and occupational hazards associated with traditional PCI. Patients with coronary artery disease and clinical indication for elective PCI were enrolled. The coronary angioplasty procedure was performed with the CorPath 200 robotic system (Corindus, Inc., Natick, Massachusetts). The system consists of a remote interventional cockpit and a multicomponent bedside unit that enables the operator to advance, retract, and rotate guidewires and rapid exchange catheters. The primary endpoint was device clinical success (≤ 30% residual stenosis) without in-hospital major adverse cardiac events. Technical success was defined as the ability of the system to complete all the planned angioplasty steps on the basis of procedural segments. Patients were followed up to 30 days after angioplasty procedure. A total of 8 patients were enrolled in the study. The primary endpoint was achieved in all patients (100%). The technical success of the robotic system was 97.9% in completing 47 of 48 planned steps. There were no device- or procedure-related complications and no in-hospital or 30-day major adverse cardiac events. The operators rated the robotic system performances as equal to or better than manual procedures in 97.5% of the cases. The operator radiation exposure was 97% lower than the levels found at the standard table position. Early clinical experience with a robotic-assisted angioplasty system demonstrated feasibility, safety, and procedural effectiveness comparable to manual operation. In addition, the total operator exposure to radiation was significantly low. A larger study is warranted to verify the safety and effectiveness of robotic-assisted percutaneous coronary intervention.

All comers 5 french transfemoral percutaneous coronary intervention without sheath

There is an interest to keep the arterial access site for percutaneous coronary interventions (PCI) small. Using sheaths for introduction of arterial catheters is standard. The effective outer diameter of the usual introducer sheaths is about 1.5 French (F) larger than the labeled size. Omitting the sheath affords a smaller access without loss of working lumen. PCI was performed with sheathless 5 F guiding catheters in 503 consecutive all comers via femoral access. Diagnostic assessment of the coronary arteries was performed at the beginning using 4 F diagnostic catheters with 4 F sheaths in 293 patients (58%). In the remaining patients, a sheathless 5 F Amplatz left 2 (AL2) guiding catheter was used for both diagnostic study and PCI. Data analysis was performed retrospectively using catheterization reports and hospital summaries. PCI without sheath was successful in 500 of 503 patients (99%).Balloon coronary angioplasty only was performed in 155 (31%) patients, and stenting in 346 (69%). In six patients, a 6 F sheath and catheter were used additionally for various reasons. Femoral closure devices were used in 23 patients (5%). The femoral access complication rate was 5% with a major hematoma in 2%. In-hospital mortality and Q-wave myocardial infarction rate were both 0.2% (one patient each). A single AL2 guiding catheter with 17 exceptions and an average of 1.1 coronary guidewires per case were used. No direct complications regarding the 5 F access without a sheath were noted. Mean hospitalization time was 2.2 ± 1.5 (range 1-25) days. The 5 F PCI without sheath can be performed safely in all comers. Vascular access bleeding complication rates were comparable, if not lower than with the conventional 6 F interventions with or without closure devices. The savings in material are substantial.

Ex vivo hemodynamic assessment of mechanical aortic valve gradients using a high‐fidelity pressure wire

Accurate assessment of prosthetic mechanical valve malfunction is challenging for non-invasive and invasive techniques. We evaluated a 0.014-inch pressure-sensing coronary guidewire to assess mechanical valve dysfunction. Several case reports have shown that transaortic pressure gradients can be recorded using a 0.014-inch guidewire during cardiac catheterization. We performed an ex vivo study measuring the effects of sequentially crossing the center of each valve with a 6 French coronary angiographic catheter, a 0.035-inch guidewire, and a 0.014-inch pressure-sensing guidewire on valve dysfunction using the following 23 mm bileaflet and tilting-disc aortic valves: St. Jude Regent™, CarboMedics, Medtronic Hall™, and Björk-Shiley Monostut. A left heart model pulse duplicator recorded 10 consecutive cycles. For all valves, the greatest increase in valve regurgitation occurred with the 6 French catheter, causing a reduction in aortic valve back pressure and cardiac output, with an increase in leakage rate, regurgitant fraction, and energy loss. In comparison to the 0.035-inch guidewire, the 0.014-inch guidewire had greater regurgitation for St. Jude, lower for Medtronic Hall, and equivalent for CarboMedics and Björk-Shiley valves. For the CarboMedics valve, the 0.035-inch guidewire caused a significant increase in regurgitant fraction and energy loss, while the pressure wire had no change compared to baseline. The degree of regurgitation caused by the 0.014-inch guidewire varies with the type of mechanical aortic valve. While prior case reports have shown that valve hemodynamics may be measured using a pressure-sensing guidewire, valve regurgitation occurs when crossing a St. Jude, Medtronic Hall, or Björk-Shiley aortic valve.

Hairpin‐trap: A novel stent retrieval technique

We report a novel technique for retrieving lost stents or other equipment from the intravascular space. A hairpin is formed at the distal part of a 0.014 inch coronary guidewire, inserted through the Touhy valve, and used to "hook" the lost stent. The distal tip of the wire is then pulled back into the guiding catheter, where it is trapped by a balloon, forming a "hairpin-trap." The entire system is subsequently withdrawn. © 2010 Wiley-Liss, Inc.

The Petal dedicated bifurcation stent

Description of the Petal dedicated bifurcation drug-eluting stent The Taxus Petal (Boston Scientific Corporation, Natick, MA, USA) dedicated bifurcation device is a paclitaxel-eluting, side-branch access stent delivered over two coronary guidewires, enabling maintenance of side-branch access throughout the procedure. The body of the stent is deployed by inflation of a standard cylindrical balloon, and the side-branch “petal” struts are expanded by inflation of a smaller elliptical balloon (Figure 1). The balloon lumens (main and side-branch) are connected, permitting simultaneous balloon inflation using a single inflation device (Figure 1). The petal strut elements (Figure 1) project approximately 2 mm into the side branch providing mechanical support and applying anti-proliferative drug to the side-branch ostium, a common site for restenosis after bifurcation stenting procedures. When the Petal is delivered to a bifurcation lesion, separation of markers confirms rotational alignment of the SB elements with the SB (Figures 1 and 2). The Boston Scientific Petal stent is an improved version of a bare metal Petal stent made by Advanced Stent Technologies. The current laser cut design uses a novel, more radio-opaque platinum chromium alloy that is associated with greater visibility than stainless steel or cobalt chromium (Figure 3). The alloy is also stronger, allowing construction of stents with thinner struts but with maintained radial strength and minimal recoil. The drug (paclitaxel) and polymer (translute) are the same as those coating the Taxus Express and Taxus Liberte stents and evaluated in clinical trials. The stent/ delivery system profile allows delivery through a 7 Fr guide catheter.

Intravascular ultrasound-guided percutaneous coronary interventions with minimum contrast volume for prevention of the radiocontrast-induced nephropathy: report of two cases

Radiocontrast-induced nephropathy (CIN) is one of the most serious complications of percutaneous coronary interventions (PCI). The prevention of PCI-related CIN for chronic kidney disease (CKD) patients has not been established yet. The intravascular ultrasound (IVUS) is commonly used as an imaging device during PCI. We performed IVUS-guided PCI while only using fluoroscopic imaging and without administering any routine contrast dye injection during the procedures. All patients underwent a baseline coronary angiography prior to the elective PCI. During the PCI, all the following procedures were done with X-ray fluoroscopic imaging without or with a minimized contrast dye injection: the engagement of the guiding catheter, insertion of the coronary guidewire, insertion of the IVUS catheter, the stent deployment and the post-dilatation. The diameter and the length of the balloon and the stent were determined according to the pre-procedural IVUS findings, and the end point of the stent dilatation was also judged according to the acquired minimal cross-sectional area of the stent. Here we report our findings from two cases representative of IVUS-guided minimum contrast PCI in which the volumes of contrast dye during the procedure were 5 and4 ml, respectively. No CIN occurred after either procedure. The IVUS-guided minimum contrast PCI could be a promising option for the prevention of CIN after PCI.

Retrieval of lost coronary guidewires during challenging percutaneous coronary interventions

The presence of symptomatic or asymptomatic intravascular/intracardiac foreign body (FB) is underreported in the literature, but it is more commonly encountered in clinical practice. Nowadays, losing a coronary stent or a guidewire has become a rare event. However, due to the constant increase in the total number of worldwide performed coronary interventions (PCI) and especially due to an increase also in the technical difficulties of these procedures (i.e., new devices+complex techniques), this kind of "lost FB complication" may again become clinically relevant. We report two cases where, during challenging PCIs, 0.014-in. guidewires broke, remaining firmly anchored in the coronary tree floating with their proximal part in the aorta. These wires could have been successfully retrieved with a dedicated three-dimensional snare device, which is specifically manufactured for facilitating this kind of retrieval interventions. Intracoronary lost guidewires, if untreated, may lead to serious cardiovascular complications, suggesting that one should attempt every possible maneuver to retrieve them from the coronary circulation. By describing the peculiarity of the Entrio snare device, we finally suggest that this kind of dedicated three-dimensional snare device is an excellent tool at cardiologists' disposal for retrieving intracardiac and intravascular lost wires.

Removal of broken balloon mitral valvotomy coiled guidewire from giant left atrium using indigenous snare

Balloon mitral valvotomy (BMV) is a safe and effective therapy for rheumatic mitral stenosis. During the procedure, the coiled portion of 0.025in. stainless steel BMV guidewire broke off within the giant left atrium (LA). Attempts to retrieve the guidewire with various snares failed as it was moving freely within the voluminous LA. We describe a technique wherein the broken guidewire was retrieved with a snare made of 0.014in. percutaneous transluminal coronary angioplasty guidewire. The mechanism and prevention of this complication and management options are discussed.

Coronary guidewire circumcision during use of a gopher support catheter: Potential adverse interaction with polymer‐jacketed wire design

Support catheters with a threaded, distal tip may be useful for crossing recalcitrant coronary lesions. The interaction between the Gopher support catheter and polymer-coated coronary guidewires may, however, result in circumferential stripping of polymer from the guidewire, with resulting wire damage or fracture. We report two cases of polymer-coated guidewire damage with use of a Gopher support catheter, suggesting that these two devices should not be used together.

Coronary guidewires

Coronary guidewires

A New Fixed-wire, ‘Stent-on-a-wire’, Very-low-profile Stent Delivery System – Rationale, Design and Update

Coronary artery stenting has evolved substantially since the first use of coronary stenting as an adjunct to balloon angioplasty in the early 1990s. The performance (and particularly the deliverability) of coronary stents has improved such that coronary stenting is now the primary mode of revascularisation for percutaneous coronary interventions (PCIs) in more than 95% of cases. The new Svelte™ stent-on-a-wire (SOAW) delivery system represents one of the first substantive innovations in stent delivery systems (SDS) in more than a decade. This SDS uses a shapeable ‘fixed wire’ as an integral part of the SDS. This allows a significant reduction in SDS profile (~0.029 inches) compared with conventional monorail or over-the-wire SDS. This SOAW SDS is intended to facilitate direct stenting. It has the potential to provide substantial procedural cost savings by eliminating the need for a coronary guidewire and balloon pre-dilatation and/or post-dilatation, and by reducing contrast use and the time required to complete the procedure. The SOAW system is compatible with 5Fr guiding catheters, and may reduce the need for closure devices, facilitate stenting via the radial approach and (potentially) reduce bleeding risks. In conclusion, the Svelte SOAW SDS represents a new very-low-profile balloon-expandable SDS that should promote direct stenting in PCIs. The efficiency and small profile of this SDS may allow procedural cost savings, a reduction in procedure time and a reduced risk of bleeding complications. These theoretical advantages will need to be demonstrated in clinical trials.

Changing the guiding catheter over the coronary wire: a simple (and cheap) technique to get out of trouble

During acute myocardial infarction (MI), the culprit lesion is usually composed of thrombus and soft plaque. Sometimes, calcification can be present.A patient with acute MI, due to sub-occlusion of the ostial right coronary artery, underwent primary percutaneous intervention.The procedure was complicated by severe dissection after balloon inflation.The use of standard materials did not allow stent passage, due to an underestimated severe calcification.To provide better support, we changed the guiding catheter for a more supportive one over the coronary guidewire, left in place to avoid rewiring the false lumen. This technique allowed successful stent deployment.

Usefulness of the index of microcirculatory resistance for invasively assessing myocardial viability immediately after primary angioplasty for anterior myocardial infarction

The aim of this study is to evaluate the usefulness of the index of microcirculatory resistance (IMR) for predicting myocardial viability and left ventricular (LV) function recovery in acute myocardial infarction (AMI). After successful primary percutaneous coronary intervention in 40 patients with anterior AMI, IMR was measured using a pressure-temperature sensor-tipped coronary guidewire. Myocardial viability was quantified by 18F-fluorodeoxyglucose (FDG) positron emission tomography in 38 patients. Echocardiographic regional wall motion was analysed to calculate the anterior wall motion score (A-WMS) and percent change in A-WMS after revascularization and at 6-month follow-up. IMR correlated significantly with regional myocardial FDG uptake (r = -0.738, P < 0.001) and it demonstrated significant correlation with percent change in A-WMS (r = -0.464, P = 0.003). The area under the receiver operating curve of IMR for predicting LV function recovery was 0.89 [95% CI 0.888-0.894]. Index of microcirculatory resistance, a new index representing microvascular integrity, is a reliable early on-site determinant of myocardial viability and LV recovery after primary stenting for AMI.

Mitral Cerclage Annuloplasty, A Novel Transcatheter Treatment for Secondary Mitral Valve Regurgitation: Initial Results in Swine

We developed and tested a novel transcatheter circumferential annuloplasty technique to reduce mitral regurgitation in porcine ischemic cardiomyopathy. Catheter-based annuloplasty for secondary mitral regurgitation exploits the proximity of the coronary sinus to the mitral annulus, but is limited by anatomic variants and coronary artery entrapment. The procedure, "cerclage annuloplasty," is guided by magnetic resonance imaging (MRI) roadmaps fused with live X-ray. A coronary sinus guidewire traverses a short segment of the basal septal myocardium to re-enter the right heart where it is exchanged for a suture. Tension is applied interactively during imaging and secured with a locking device. We found 2 feasible suture pathways from the great cardiac vein across the interventricular septum to create cerclage. Right ventricular septal re-entry required shorter fluoroscopy times than right atrial re-entry, which entailed a longer intramyocardial traversal but did not cross the tricuspid valve. Graded tension progressively reduced septal-lateral annular diameter, but not end-systolic elastance or regional myocardial function. A simple arch-like device protected entrapped coronary arteries from compression even during supratherapeutic tension. Cerclage reduced mitral regurgitation fraction (from 22.8 +/- 12.7% to 7.2 +/- 4.4%, p = 0.04) by slice tracking velocity-encoded MRI. Flexible cerclage reduced annular size but preserved annular motion. Cerclage also displaced the posterior annulus toward the papillary muscles. Cerclage introduced reciprocal constraint to the left ventricular outflow tract and mitral annulus that enhanced leaflet coaptation. A sample of human coronary venograms and computed tomography angiograms suggested that most have suitable venous anatomy for cerclage. Transcatheter mitral cerclage annuloplasty acutely reduces mitral regurgitation in porcine ischemic cardiomyopathy. Entrapped coronary arteries can be protected. MRI provided insight into the mechanism of cerclage action.

Usefulness of a 0.010-inch guidewire compatible balloon for crossing stent-jailed sidebranches

Failure of the balloon to pass through for a side branch in spite of wire crossing occasionally occurs due to a jailed stent during treatment of bifurcation lesions. In this report, we describe a novel 0.010-inch coronary guidewire compatible balloon (IKAZUCHI 10™ ) that is effective for crossing a side branch through the jailed stent strut, while another standard 0.014-inch guidewire compatible small balloon was unable to cross the same lesion. This novel 0.010-inch guidewire compatible balloon may be useful for a side branch that is difficult to cross through the stent strut.