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`GUIDELINER® CATHETER
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`The "Child-in-Mother”Technique:
`Successful Transradial Use of the
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`GuideLiner Catheter in a Heavily
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`calcified Circumflrex Artery
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`PHYSICIAN
`Jack P. Chen, MD, FACC, FSCAI
`Saint Joseph's Heart and Vascular Institute, Atlanta, GA
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`PRESENTATION
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`The patient had undergone robotic totally endoscopic
`coronary artery bypass (TECAB) involving the left internal
`mammary artery (LIMA) to the left anterior descending
`artery (LAD) two years prior. Subsequently, the patient
`developed distal LIMA anastomotic stenosis, as well as severe
`progression of disease in the left circumflex artery (LCX) and
`right coronary artery (RCA).
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`At repeat bypass surgery (with sternotomy), saphenous vein
`grafts (SVGs) were anastomosed to the LAD, first obtuse
`marginal branch (OMI ), and right posterior descending artery
`(PDA). The LIMA was tied off at the distal anastomosis to
`enhance SVG—LAD flow.
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`The patient recently developed recurrent angina.
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`INITIAL FINDINGS
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`Transradial cardiac catheterization revealed patent SVGs
`to the 0M1 and PDA. However, the SVG to the LAD was
`occluded ostially. The native LCX was a calcified vessel, with
`a very angulated origin from the left main artery. There were
`stenoses in the proximal and distal LCX (Figure I). The native
`OMI was totally occluded proximal to the anastomosis, and
`there was no retrograde perfusion of the LCX. The LAD had a
`chronic total occlusion proximally, as did the RCA. The LIMA
`was not imaged.
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`TREATMENT
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`It was decided to proceed with hybrid TECAB-LAD and
`stent-LCX. Transradial PCI was performed with initial balloon
`predilatation with a 2.0mm x 15mm Sprinter® balloon (Figure
`2). However, the marked LM-LCX angulation and severe arc
`(270”), coupled with marked calcification, prevented stent
`advancement despite use ofa stiff wire. A 6F compatible
`GuideLiner catheter, likewise, could not be advanced into the
`proximal arc.
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`(continued on back)
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`TREATMENT OF CIRCUMFLEX ARTERY
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`The original balloon was re—advanced through the GuideLiner
`into the distal vessel; the GuideLiner was subsequently
`inserted slowly into the proximal LCX, using sequential short,
`firm advancements.
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`Once the GuideLiner was positioned in the proximal LCX, two
`3.5mm x 18mm Driver® bare metal stents were deployed in
`the mid and proximal lesions without a problem (Figures 3 &
`4). However, the intervening vessel segment now appeared
`narrowed.
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`A third 3.5mm x I 8mm Driver stent would not traverse the
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`previously deployed proximal stent. The GuideLiner catheter
`was once again advanced, this time through the proximal
`stent to avoid "stent—on—stent" friction. The third stent was
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`easily deployed after advancing through the GuideLiner,
`between the two previous stents (Figure 5).The final result
`was excellent (Figure 6).
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`The patient subsequently underwent uneventful repeat
`TECAB utilizing a free right internal mammary artery segment
`as a ”jump graft”anastomosed to and bridging the distal LIMA
`and the mid-LAD. Unfortunately, this free RIMA graft segment
`also developed diffuse stenosis a few months subsequently,
`necessitating further DES implantation via the LIMA graft.
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`CONCLUSION
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`This case illustrates the value ofthe"child-in-mother”technique
`of deep catheter engagement to facilitate difficult device
`advancement.
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`Advancement of additional stents through a previously
`deployed proximal stent can be challenging. When positioned
`through a deployed stent, the GuideLiner acted as a smooth
`sleeve or inner lining allowing passage ofthe new stent.
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`Additionally, it is not uncommon to observe concomitant guide
`catheter disengagement or back-out from the coronary ostium
`with GuideLiner advancement. This is not a concern, as the
`intracoronary GuideLiner offers substantial back—up support.
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`
`
`Jack P. Chen, MD, FACC, FSCAI
`Dr. Chen received his MD. from Weill—Cornell
`Medical College. He completed his Cardiology
`fellowship at New York—Presbyterian Hospital. As
`an Interventional Cardiologist, Dr. Chen serves as
`the Medical Director of Cardiology at Northside
`Hospital and is the Director for Cardiac Studies
`at Saint Joseph's Translational Research Institute
`(Saint Joseph’s Hospital) in Atlanta, Georgia.
`
`GuldeLinercatheters areintended to be used in conjunction with guide catheters to access discrete regions ofthe coronary
`and/or peripheral vasculature, and to facilitate placementand exchange ofguideWIres and other interventional devices.
`Pleasesee the lnstructlonsfor Use fora complete listing ofthe indications, contraindications, warnings and precautions.
`CAUTION: Federal law (U.S.A.) restricts this deviceto sale by or on theorder of a physician.
`GuideLiner is a registered trademarkofVascularSolutions, Inc.
`All otliertrademarks and registered trademarks are property oftlieir respective owners.
`©2016VascularSolutions,Inc.Allrightsreserved.ML1:I74Rev.B10/16
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`Vascular Solutions, Inc.
`6464 Sycamore Court North
`Minneapolis, Minnesota 55369 USA
`Customer Service:
`United States: 888.240.6001
`International: (001) 763.656.4298
`customerservice@vasc.com
`WWW.V85C.C0m
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`VSIQXM_EOOO44664
`
`Teleflex Ex. 2187
`
`Medtronic v. Teleflex
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`IPR2020-00135
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`Page 2
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`Teleflex Ex. 2187
`Medtronic v. Teleflex
`IPR2020-00135
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