Guide Catheter Support Research Articles

Guiding catheter extension compatibility for high speed rotational atherectomy.

Coronary calcification is one of the features that characterize atherosclerosis. The location of a calcific plaque may vary from case to case [1]. Some distal locations may affect procedural outcomes of coronary angioplasty, resulting in impaired device deliverability. In these cases, guiding extension catheters have been widely introduced into practice to overcome the problem of poor deliverability and guiding catheter support. In some patients, calcified lesions are located distally and rotational burr deliverability is also impaired. The aim of this study was to test the commercially available guiding extension catheters in terms of compatibility of these devices with rotational atherectomy burrs outside the patient’s body.

Anomalous Right Coronary Artery Origin from Left Sinus (R- ACAOS) Coronary Intervention Case Series; “Our Approach” - A Single Center Experience

Anomalous origin of right coronary artery (RCA) from the left coronary sinus is very rare coronary anomaly. Various individual case reports and case series have been reported in the literature. Patients with anomalous right coronary artery may often be asymptomatic and detected on incidental CT coronary angiogram or at times may present with acute coronary syndrome, sudden cardiac death or malignant arrhythmias. Coronary intervention in an anomalous right coronary artery is often challenging and any interventionist should be familiar with the incidence of this anomaly and always choose an optimal, safe and a good co- axial guiding catheter support for a successful intervention. Here, we present three individual cases with anomalous RCA presenting with positive stress test to acute coronary syndrome. All three cases underwent successful intervention with Judkins left 3.0 (JL 3.0) guiding catheter without any perioperative complications.

An algorithmic approach to balloon-uncrossable coronary lesions.

Balloon uncrossable coronary lesions are lesions that cannot be crossed with a balloon after successful guidewire crossing. The strategies used to facilitate the treatment of such lesions can be classified into strategies that provide lesion modification and strategies that increase support. We describe a systematic, algorithmic approach to treat balloon uncrossable lesions, starting with use of small balloons, followed by increase in guide catheter support, use of microcatheters, wire cutting or puncture techniques, laser, atherectomy, and subintimal modification techniques. Sequential and simultaneous application of the aforementioned techniques can result in successful treatment of these challenging lesions.

Radial Versus Femoral Access in Chronic Total Occlusion Percutaneous Coronary Intervention

Background Radial access (RA) is increasingly used in chronic total occlusion (CTO) percutaneous coronary intervention with encouraging results. However, there are concerns about its safety and efficacy because of higher complexity and the need for strong guide catheter support. Methods and Results We performed a systematic review and meta-analysis of all studies published through November 2018 reporting the outcomes of RA versus femoral access in CTO percutaneous coronary intervention. Outcomes included major bleeding, access-site complications, in-hospital major adverse events, and technical success. Nine observational studies with 10 590 patients (10 617 lesions) were included in the meta-analysis. CTO lesions attempted using RA had lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P<0.001). Use of RA was associated with similar technical success (78.7% versus 78.5%; odds ratio, 1.11; 95% CI, 0.94-1.31; P=0.24; I2=23%), lower risk of access-site complications (0.73% versus 1.79%; odds ratio, 0.34; 95% CI, 0.22-0.51; P<0.001; I2=0%) and major bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10-0.45; P<0.001; I2=0%), and similar risk of in-hospital adverse events and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12-1.07; P=0.07; I2=0%) as compared to femoral access. Results were similar when analyzing radial-only versus any femoral access and when excluding the largest study. Conclusions As compared with femoral access, RA is used in CTO percutaneous coronary intervention of less complex lesions and is associated with fewer access-site complications and major bleeding and comparable technical success.

Balloon-assisted guide catheter tracking: An innovative technique for anomalous right coronary artery stenting

The most important factor for a successful percutaneous coronary intervention of an anomalous right coronary artery arising from left sinus is coaxial alignment of guide catheter and adequate backup support. In this report, we describe a novel case in which we used a distally parked balloon to assist in tracking and proper alignment of the guide catheter.

Successful Retrograde Recanalization of a Very Rare Anomalous Origin Right Coronary Artery Chronic Total Occlusion

Chronic total coronary occlusions (CTO) still remain one of the most technically challenging clinical scenarios in which to perform interventions. Although the antegrade approach is the most common method of CTO recanalization, a retrograde attempt improves the success rate and its usage has been increasingly adopted in the recent years. Furthermore, abnormalities such as anomalous origin coronary arteries represent other important technically challenging cases for interventional cardiologist. In this case, we describe a rare case of a CTO in the mid portion of an anomalous right coronary artery (RCA), that originated from a high anterior takeoff and progressed in the downward direction, where retrograde approach has been used to overcome the absence of antegrade guiding catheter support.

Successful Transcatheter Retrieval of the Embolized Coronary Stent During Primary Percutaneous Coronary Intervention

Stent dislodgement or embolization occuring during primary percutaneous coronary intervention (PCI) is a very seldom and potentially serious complication related to neurological events and peripheral arterial ischemia, loss of time and thus delayed optimal revascularization, resulting in worse outcomes. The most probable conditions associated with a higher risk of stent embolization are severe coronary lesion features (i.e., angulated vessel or calcified lesion), inadequate support of the guiding catheter, and physical properties of the stent used. Non-surgical and, if needed, cardiac or peripheral surgical retrieval techniques can be used for this complication. We report a case of embolization of a zotarolimus-eluting coronary stent into peripheral circulation during primary PCI and its successful retrieval using a snare catheter. J Med Cases. 2016;7(10):417-419 doi: http://dx.doi.org/10.14740/jmc2481w

A Novel Technique for Percutaneous Coronary Intervention for Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva.

Percutaneous coronary intervention (PCI) for anomalous right coronary artery (RCA) arising from the left sinus of Valsalva (LSOV) is a technical challenge due to inadequate guiding catheter support to overcome the acute rightward course of the anomalous RCA. In this study we describe a novel technique for PCI for an anomalous RCA arising from the LSOV. Six patient cases with anomalous RCA arising from the LSOV who underwent PCI from January 2001 to January 2014. The Judkins left (JL) guiding catheter tip orientation is modified by manually bending at the distal tip 90° vertically to fit the acute rightward course. Of the six patients (mean age: 63 ± 16.7 years), the indication for PCI was acute inferior myocardial infarction (MI) in two, recent inferior MI in two, and angina in two of the cases. Three procedures were performed via a transfemoral approach and the other three via a transradial approach. The median duration of the intervention and total procedure time were 44 and 69.5 minutes, respectively. All patients received successful revascularization without complications. This novel technique is simple, safe and effective with a 100% procedure success rate for PCI for anomalous RCA arising from the LSOV. Anomalous right coronary artery; Left sinus of Valsalva; Percutaneous coronary intervention.

Abstract 13485: Prevalence and Treatment of “Balloon Uncrossable” Coronary Chronic Total Occlusions

Background: In percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs), inability to cross the lesion with a balloon is the second most common cause of technical failure following inability to cross the lesion with a guidewire. While various techniques have been reported for such "balloon uncrossable" CTOs, the frequency and outcomes of these techniques have received limited study. Methods: We retrospectively examined 373 consecutive CTO PCIs performed at our institution between 2005 and 2013 to determine the frequency and outcomes of “balloon uncrossable” CTOs. Results: Mean age was 63.7 ± 8.3 years and 98.9% of the patients were men. Twenty four patients (6.4%) were found to have a "balloon uncrossable" CTO. These patients had similar clinical and angiographic characteristics compared to the other CTO PCI patients (Table). Successful crossing of the lesion was achieved in 22 of 24 patients (91.7%) using a variety of techniques, such as successive balloon inflations (43.5%), microcatheter advancement (21.7%), laser (8.7%), increased guide catheter support (13.0%), and subintimal lesion crossing (13.0%) (Figure). Patients with “balloon uncrossable” CTOs had longer procedure time (184.5 ± 77.9 vs. 134.0 ± 69.0 min, p&lt;0.01), fluoroscopy time (55.2 ± 24.9 vs. 37.9 ± 20.8 min, p&lt;0.01), and received higher contrast volume (404.4 ± 137.9 vs. 351.7 ± 138.5 ml, p=0.085), but had similar incidence of major complications (8.3% vs. 3.2%, p=0.25) compared to patients without “balloon uncrossable” CTOs. Conclusion: “Balloon uncrossable” CTOs occur in 6.4% of contemporary CTO PCIs and can be successfully treated in most patients using a variety of techniques.

Use of ‘Guideliner’ catheter to overcome failure of delivery of Absorb™ Bioresorbable Vascular Scaffold in calcified tortuous coronary lesions: Technical considerations in ‘Real World Patients’

In our series of 177 real world patients (223 lesions) who underwent Absorb Bioresorbable Vascular Scaffold (BVS) implantation, 78 lesions were calcified and tortuous lesions. In four of these, despite adequate lesion bed preparation, appropriate guiding catheter support and use of buddy wires, the BVS failed to track through the proximal calcified and tortuous coronary anatomy (CTCA). “Guide Liner” catheter (GLC) had to be finally used to resuccessfully deliver and implant BVS to the lesion site.We report for the first time four cases of use of guideliner catheter to successfully overcome failed delivery of BVS to the lesion site through proximal CTCA, calcified and tortuous coronary artery (CTCA) lesions treated with Absorb™ BVS. Because the BVS is a large profile device, certain difficulties were encountered in delivering it through the GLC, which were finally overcome. We have therefore discussed the ‘lessons and learnt’ and “salient practice points” to enable successful delivery of BVS through the GLC.

Percutaneous Treatment of Coronary Chronic Total Occlusion Part 2: Technical Approach.

Dual injection is recommended for nearly all chronic total occlusion (CTO) percutaneous coronary intervention (PCI) to determine the optimal crossing strategy and guide wire advancement into the distal true lumen. Strategies that provide enhanced guide catheter support (such as long sheaths, large-bore guiding catheters, use of guide catheter extensions, and anchor techniques) are important for maximising the success rate and efficiency of CTO PCI. Use of a microcatheter or over-the-wire balloon is strongly recommended in CTO PCI for enhancing the penetrating power of the guidewire, enabling change in tip shape and allowing guidewire change (stiff CTO guidewires are not optimal for crossing non-occluded coronary segments). Adherence to a procedural strategy that standardises CTO technique and facilitates procedural success is recommended. Such a strategy would permit stepwise decision-making for antegrade and retrograde methods; inform guidewire selection; and incorporate alternative approaches for instances of initial failure. Given the paucity of long-term outcomes with use of novel crossing techniques (antegrade dissection/re-entry and retrograde), antegrade wire escalation is the preferred CTO crossing technique, if technically feasible. Using measures to minimise radiation exposure (including but not limited to use of 7.5 frames per second fluoroscopy and use of low magnification) and contrast administration is recommended. CTO PCI is best performed at centres with dedicated CTO PCI experience and expertise. Use of crossing difficulty prediction tools, such as the J-CTO score, can facilitate the selection of cases with a high likelihood of quick crossing that can be attempted at less experienced centres.

Risk Score, Causes, and Clinical Impact of Failure of Transradial Approach for Percutaneous Coronary Interventions

To study the causes of and to develop a risk score for failure of transradial approach (TRA) for percutaneous coronary intervention (PCI). TRA-PCI failure has been reported in 5% to 10% of cases. TRA-PCI failure was categorized as primary (clinical reasons) or crossover failure. Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. From January to June 2010, TRA-PCI was attempted in 1,609 (97.3%) consecutive patients, whereas 45 (2.7%) had primary TRA-PCI failure. Crossover TRA-PCI failure occurred in 30 (1.8%) patients. Causes of primary TRA-PCI failure included chronic radial artery occlusion (11%), previous coronary artery bypass graft (27%), and cardiogenic shock (20%). Causes for crossover TRA-PCI failure included: inadequate puncture in 17 patients (57%); radial artery spasm in 5 (17%); radial loop in 4 (13%); subclavian tortuosity in 2 (7%); and inadequate guide catheter support in 2 (7%) patients. Female sex (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.95 to 5.26, p < 0.0001), previous coronary artery bypass graft (OR: 6.1; 95% CI: 3.63 to 10.05, p < 0.0001), and cardiogenic shock (OR: 11.2; 95% CI: 2.78 to 41.2, p= 0.0011) were independent predictors of TRA-PCI failure. Risk score values from 0 to 7 predicted a TRA-PCI failure rate from 2% to 80%. In a high-volume radial center, 2.7% of patients undergoing PCI are excluded from initial TRA on clinical grounds, whereas crossover to femoral approach is required in only 1.8% of the cases. A new simple clinical risk score is developed to predict TRA-PCI failure.

L’utilisation du cathéter Heartrail II « 5-in-6 » dans l’angioplastie coronaire complexe : expérience multicentrique

BackgroundThe mother and child “5-in-6” technique using the Heartrail II catheter is a novel tool allowing stent delivery in challenging lesions, when conventional techniques have failed. MethodsA total of 147 consecutive patients underwent percutaneous coronary intervention (PCI) using the “5-in-6” Heartrail II catheter was restrospectively identified in the Institut Cardiovasculaire Paris Sud, (Jacques-cartier hospital), Institut hospitalier Claude-Galien (Claude-Galien hospital) and European hospital of Paris between July 2009 and September 2012. ResultsTen interventional cardiologists treated 147 patients with the new device. The patients mean age was 68.5±21.5 years, 78% were men. Radial access was used in 128 cases (87.9%). The treated vessels were the right coronary artery in 82%, left anterior descending in 22%, left circumflex in 18%, marginal branch in 9%, the posterior descending artery in three patients, retroventricular artery in one patient and a saphenous graft in two patients. Most lesions (70%) had American Heart Association/American College of Cardiology (AHA/ACC) type B2 or C, and greater than 50% were located in distal vessel segments. Mean lesion length was 16±4mm, which is indicative of long lesion. Most (62%) lesions were moderately to heavily calcified and 22 (14%) were chronic total occlusions. Problems with stent delivery were due to poor guide catheter support or excessive calcification. Introduction of the “Heartrail II” catheter allowed successful stent delivery in 139 cases (94%). ConclusionThe “5 in 6” Heartrail II catheter is a simple and easy-to-use device that can improve the success of stent delivery in challenging coronary interventions.

Transradial interventions with the GuideLiner catheter: Role of proximal vessel angulation

Transradial coronary intervention (TRI) is increasingly common, but anatomic variations and lack of guide catheter support may increase the complexity of TRI. The GuideLiner catheter (Vascular Solutions, Minneapolis,MN) is a guide catheter extension developed to provide increased guide catheter support. We hypothesized that TRI cases requiring GuideLiner support would have a greater proximal vessel angle and increased lesion angle tortuosity. This was a retrospective study reviewing 146 TRI cases performed at a single institution between August 2010 and June 2012. 22 cases (15%) required use of the GuideLiner support catheter. Procedural and angiographic characteristics of all cases were analyzed. Multivariable analysis and receiver operator curves (ROC) were used to analyze predictors of GuideLiner use. The indications for TRI were similar between both groups. Subjects who required use of the GuideLiner support catheter at the time of TRI were significantly older (69±12years vs. 62±13years, p=0.03). The proximal vessel angle was significantly greater in the cases requiring GuideLiner support (74°±35° vs. 37°±23°, p<0.001). Lesion angle in the Guideliner group was also significantly greater (48°±32° vs. 28°±25°, p<0.001). On multivariable analysis, proximal vessel angle independently predicted the need for GuideLiner support (AOR 1.4 per 10°, p<0.001). A 45° proximal vessel angle predicted the need for GuideLiner use with a sensitivity of 73% and specificity of 74% (c-statistic 0.79). None of the Guideliner TRI cases required conversion to femoral access. TRIs requiring GuideLiner catheter support had significantly increased lesion complexity and vessel tortuosity. Proximal vessel angulation is significantly associated with the need for GuideLiner use during transradial intervention. Use of the Guideliner facilitated successful completion of PCI despite the use of a wide variety of guiding catheters in this series.

E-060 Utilisation of the Navien Distal Intracranial Catheter for Ultra-Distal Large-Bore Intracranial Access in the Treatment of Cerebrovascular Pathologies

BackgroundSuccessful neuroendovascular treatments rely on microcatheter stability from guide catheter support. We present our experience using a new large-bore, 0.058″ or 0.072″ inner diameter (ID), hyperflexible access catheter placed deep...

Rotastenting in an anomalously arising right coronary artery after an ugly dissection

Rotational atherectomy is contraindicated in dissected coronary arteries since it can lead to progression of the dissection or perforation. In our case, the right coronary artery (RCA) arose anomalously from the left coronary sinus. The lesion in the RCA was an undilatable calcified one. There was a dissection in the RCA due to high pressure balloon dilatation. Since the patient was hemodynamically unstable and there were no options besides rotablation, we proceeded with caution. Rotablation and stenting were successfully done. Our case report highlights the importance of the need for good guide catheter support even in the presence of anomalously arising arteries and the rotablation option for unyielding calcified coronary lesions, even in the setting of a dissection.

Ultra-distal large-bore intracranial access using the hyperflexible Navien distal intracranial catheter for the treatment of cerebrovascular pathologies: a technical note

BackgroundSuccessful neuroendovascular treatments rely on microcatheter stability from guide catheter support. We present our experience using a new large-bore 0.058 inch or 0.072 inch inner diameter (ID) hyperflexible access catheter...

Chronic total occlusions: Successful recanalization of very old lesions

The treatment of chronic total occlusion is thought to be the final frontier in treating coronary artery disease nonsurgically. In the past, an old occlusion was not likely to be treated successfully percutaneous. We have had success in revascularizing some very old 20 plus year old occlusions percutaneously. Six patients were treated who had >20-year-old occlusions. Five patients were male; mean age of patients was 72.2 years (range 63-86). Mean age of the occlusion was 24.8 years. All patients had ischemia in the corresponding territory. Four of the patients had right coronary artery occlusions; one had a left circumflex occlusion and one had left anterior descending artery occlusion. Using a combination of radial and/or femoral approach, we successfully recanalized all of these old occlusions. No patients had major adverse cardiac events. Two patients developed restenosis at follow-up that was subsequently treated uneventfully. All the patients had a complete relief of angina. In a small single center experience, even very old occlusions >20-year old can be effectively treated with dedicated systems, excellent guiding catheter support and experienced physicians.

Transulnar approach as an alternative access site for coronary invasive procedures after transradial approach failure

Unsuccessful radial artery puncture, inability to advance the guide catheter to the ascending aorta, and inadequate guide catheter support represent mechanisms of transradial approach failure. With the rationale of sharing the same efficacy and safety promoted by radial access, the transulnar approach represents an alternative access site for percutaneous coronary procedures. Between May 2007 and May 2012, 11,059 coronary invasive procedures were performed in a single institution: 10,108 by transradial approach (91.4%), 541 by transfemoral approach (4.9%), and 410 by transulnar approach (3.7%). Patients who underwent coronary procedures through transulnar access were included in a prospective registry of effectiveness and safety. Diagnostic procedures accounted for 71.8% of cases, and the right ulnar access was the most common route (88.9%). Procedure success was high (98.5%), with a crossover rate of 1.5% (6 cases), of which 5 were achieved through the contralateral radial access and 1 through femoral approach. Complications related to access site were low (3.9%), consisting mostly of minor bleeding due to subcutaneous hematomas. There were no cases of major bleeding, nerve injury, pseudoaneurysm, arteriovenous fistula, or necessity of vascular surgical repair. The transulnar approach represents an alternative to the transradial approach in selected cases when performed by radial-trained operators, sharing a high success rate and extremely low incidence of access-site complications.

E-018 Initial experience with distal guide catheter placement in the treatment of cerebrovascular disease: clinical safety and efficacy

BackgroundThe treatment of cerebrovascular diseases continues to grow with improvements in technology. The use of stable guide catheters in the large cervical cerebral vessels has historically been paramount to the...