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`
`
`Abstract
`
`Aims: Optimal ostial seating and adequate back—up ofguide catheters are required for challenging percutane—
`ous coronary interventions (PCl ). The GuideLinerl'M (GL) (Vascular Solutions Inc. Mirureapolis, MN, USA)
`is a guide catheter extension system that provides active back—up support by deep coronary intubation. We
`aimed to assess feasibility and safety of GL—use in routine clinical practice.
`
`were no major complications.
`
`Methods and results: We prospectively recorded patient and procedural details, technical success, and in—
`hospital outcome of 65 consecutive patients undergoing “5-in-6” Fr GL-facilitated PCI of 70 target vessels. The
`GL was mainly used for PCI of complex coronary lesions: 97% (68/70) had American HeartAssociation/Aineri—
`can College of Cardiology (AHA/ACC ) lesion types BZ/C, 53% (37/70) were distally located; and 23% (17/70)
`were heavily calcified. Indications were to increase back-up of the guide and facilitate stent delivery (59%;
`41/70). achievement of coaxial alignment of the guide catheter (29%; 20/70), and selective contrast injections
`(13%; 9/70). Device success rate was 93% (65/70). There were no major complications and two minor coinpli—
`cations managed without clinical sequelae; one air embolism and one stent dislodgement.
`
`Conclusions: GL-use resulted in increased back—up and guide catheter alignment for stent delivery in unfa—
`vourable tortuous coronary anatomies and complex, heavily calcified, and often distally located lesions,
`which otherwise may have been considered unsuitable for PCI. Procedural success rate was high and there
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`Merrie Gulcetlner registry
`
`*3:3
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`wearersfern;m
`
`
`
`Abbreviations
`ACS
`acute coronary syndrome
`CK
`creatine kinase
`CTO
`chronic total occlusion
`
`DES
`GEA
`GL
`
`LAD
`LDX
`LM
`
`ch’ug—eluting stents
`gastroepiploic artery
`GuideLiner
`
`left anterior descending coronary artery
`left circumflex coronary artery
`left main
`
`NSTE MI non-ST—elevation myocardial infarction
`PCI
`percutaneous coronary intervention
`STE MI
`ST—elevation myocardial infarction
`RCA
`right coronary artery
`UAP
`unstable angina pectoris
`
`lutraduetton
`Despite the advancements made in percutaneous coronary interven—
`tions, the interventional cardiologist nowadays has to deal With an
`increasing complexity of procedures. A good back-up of the guide
`catheter is essential to advance guidewires and balloons, and to
`deliver stents. Support of the guide can be increased by use of extra
`back—up guides and larger guide dimensions. In addition, the stabil-
`ity of the guide can be improved by advancing a buddy wire, and
`use of stiffer guidewires or anchoring balloons”. Another way to
`increase back—up support is deep intubatiori of the guide“. There is,
`however, a considerable risk of dissecting the vessel. Introduction
`of guide catheter extension systems, in which a long guide catheter
`with a flexible tip is advanced through the mother guide, has further
`refined this concept“. Besides the improvement in back—up sup-
`port, the use of guide catheter extensions provides selective visuali-
`sation of the target vessel, improves the stability of the guide and
`allows coaxial alignment of the guide.
`
`There are three systems available; the I'Ieartrail® II catheter ('I‘erumo
`Corp, Tokyo, Japan), the ProxisTM device (St Jude Medical, St Paul,
`MN, USA) and the GuideLinerTM catheter (Vascular Solutions Inc,
`Minneapolis, MN, USA). The Heartrail® II catheter and ProxisTM device
`are 120 cm catheters that are introduced into the mother guide by remov—
`ing the Y—connector”. The GuideLiner (GL) catheter (Figure 1) is
`a novel rapid exchange guide catheter extension system that provides
`active guide supp01t by its 20 crn—long flexible tubular end, which can be
`deeply advanced into target vesselsw'lg. Its handling is particularly easy.
`as it is does not require disconnection of the haemostatic valve at the
`proximal end of the guide catheter and is compatible with standard
`180 urn—long gludewires. Its soft distal tip pronnses a low risk ofdissect—
`ing vessels compared to the deep-seating ofregular guide catheters.
`So far, only a limited number of reports and case series have been
`published on the (J‘L guide catheter extension] 0'18. Mamas et al
`reported a case series of IS complex coronary interventions, per—
`formed Via the radial artery with the “5—in—6” Fr GL system”.
`Although their success rate was high. the main limitation encoun—
`tered was stent damage upon advancement of the stent across the
`metallic collar of the GL (two out of 32 stents)”. Recently, Luna et
`al published their experience with the GL catheter in a series of
`21 patients”. In their study, a transfentoral approach and 7 Fr guide
`catheters were used in the majority of the cases with a procedural
`success rate of 90%. Pressure dampening was seen in 57% of their
`patients, contributing to three out of four unsuccessful cases. There
`was one maj or complication in the series reported by Lima et al,
`which was a flow—limiting dissection in the proximal left anterior
`descending coronary artery (LAD) but they noted no case of stent
`damage”. The purpose of the present Twente GuideLiner registry
`was to assess feasibility and safety of use of the “5—in—6” Fr GI,
`guide catheter extension system during routine, clinical PCI proce-
`dures as performed at Thoraxcentrum Twente, a high—volume PC]
`centre located in Enschede, The Nether ands.
`
`
`
`
`
`figure l, .S'r'isenmzie preremzmon after? Guidelrimr catheter:
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`details on the iii—hospital outcome of a consecutive series of 65
`patients, who underwent PCT with the use of the GL. Patient demo-
`graphics, indication for GL use, angiographic and procedural details
`including technical success, and all complications were recorded.
`Quantitative coronary angiogr’aphy (QCA) was used to determnie the
`intubation depth of the GL catheter. Procedural success was defined as
`the achievement of <20% diameter stenosis with TIMI 3 flow in the
`
`target vessel. Routine peri-interventional assessment of cardiac bio-
`markers was performed to screen for PCT—induced myocardial necro—
`sis up to 24 hours after PCT or until the highest value of creatine kinase
`(CK) was measured. Peri-PCT myocardial infarction was defined as
`two times the upper reference limit of CK, confirmed by significant
`elevation ofother specific biomarlcers (MB—fraction of CK or troponin).
`
`STATISTICAL ANALYSIS
`
`Values are expressed as rnea :ST). Comparison of continuous varia—
`blcs was performed with the Student’s t—test. Categorical variables
`are presented as numbers or
`ercentages and were tested with the
`chi—square test or Fisher's exact test. A p—value <0.05 was considered
`statistically significant. Statistical analysis was performed with SPSS
`version 15.0 for Windows (SPSS lnc., Chicago, 1, USA).
`
`
`
`Rest; its
`PATIENT POPULATION AND LESION CHARACTERISTICS
`
`The demographic characteristics of the study population are pre-
`sented in Table 1 . The majority of patients were male (7/ ‘31)), and the
`
`mean age was 67:13 years. Target lesions were relatively complex as
`is shown in Table 2. Most lesions (97%) had American Heart Asso-
`ciation/Aniericaii College of Cardiology (AHA/ACC) lesion types
`B2 or C, with more than half of them being located in distal vessel
`segments. A total of 90% of lesions was classified as being calcified:
`40/
`67% mild to moderately and 2.3/0 heavily calcified. Mean lesion
`
`length was 38:26 mm, which is indicative of long lesions.
`
`Table 1. Demographic characteristics of study population.
`
`
`74% (48/65)
`Male gender
`
`
`Hypertension 57% (37/61
`
`
`
`
`
`
`
`
`
`
`25% (17/65)
`
`Prior CABG
`26% (17/65)
`indication for PCI
`
`ST—eleva’rion Nil
`12% (8/65)
`
`Non-ST—elevation Ml
`20% (13/65)
`6% (4/65)
`Unstable angina
`
`62% (40165]
`Stable angina
`
` so{a
`
`a5*
`fi£35:
`
`Methods
`STUDY POPULATION
`
`Between November 2010 and July 2011, we prospectively col-
`lected data from a consecutive series of 65 patients, in whom the
`GL was applied to facilitate routine PCl. The patients had a back—
`ground of stable or unstable angina pectoris, or presented with an
`acute myocardial infarction.
`
`INTERVENTIONAL PROCEDURES
`
`A team of five iritervcntional cardiologists performed the PC] proce—
`dures; each of them had performed PC] for more than five years (250—
`500 PCI procedures per operator annually; total PCl experience of
`4,000 or more per operator). PCI procedures were performed accord—
`ing to standard clinical protocols via the femoral or radial routes, using
`6 Fr guide catheters as a standard. All patients received a bolus of
`untractionaterl heparin (5,000 FF, or 70—100 Iii/kg). Prior to PCI, all
`patients received adequate loading doses of acetylsalicylic acid
`(300 mg) and clopidogrel (300—600 mg), if not pretreated. During the
`procedure, an intracoronary bolus of nitrates was adrniiustered. The
`choice of interventional approaches, devices, and techniques was left at
`the operators’ discretion, considering current clinical protocols and
`guidelnies. Followrng PCT, clopidogrel was prescribed for one year
`(75 mg once daily [od] in addition to life—long treatment with acetyl—
`salicylic acid [at least 100 mg o.d.]).
`
`THE GUIDELINER CATHETER AND ITS USE
`
`The GT. (Vascular Solutions, Minneapolis, MN, USA) consists of
`a flexible, 20 cm, straight. flexible. soft-tipped extension tube that is
`connected via a metal collar to a thin l l 5 cm—long stainless steel shaft
`(Figure 1A and Figure 1 B). The extension tube has a silicon coating for
`lubricity. The procedure starts by positioning the mother guide and
`advancing the guidewire across the target lesion. Then the GT. is
`advanced over the guidewire through the haemostatic valve of the
`Y—adapter (handling comparable to regular balloons) to intubale the
`target coronary artery or bypass graft (Figure 10). The GL reduces the
`inner diameter of the mother guide by approximately l Fr, but it does
`not lengthen the guide outside the patient. When the GL is in place,
`balloons and stents can be delivered over the same initial guidewire.
`The GL is available in sizes of6 [7r. 7 Fr, and 8 Fr. in this study, only
`6 Fr GL were used (also called the “5—in-6” Fr system). which has an
`internal diameter ol‘ 0.056” (l .422 mm). Notably, the use in vessels
`<25 mm is discouraged by the manufacturer. Bifurcation lesions in
`our study were treated as follows: two wires were advanced through
`the guide. Then, the GL was advanced over both wires simultane—
`ously. Provisional stenting was the strategy of choice. In cases where
`a kissing balloon technique was demanded, a wire exchange was per-
`formed followed by balloon dilation of the side branch through the
`stent struts. Before the final kissing balloon inflation could be per—
`formed, the GL had to be removed.
`
`STUDY PARAMETERS AND DATA ACQUISITION
`
`To assess the usefulness (feasibility and safety) of the G1. in clinical
`practice, we prospectively recorded various procedural data and clinical
`
`CABG: coronary artery bypass graft; Ml: myocardial infarction
`
`j
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` NM:1:no
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`3373233
`1mg;2!.
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`M g
`
`Twente fitiideLirzer egetr
`
`Table 3. Procedural details, success, failures, and complications.
`
`Radial access
`22/65 (34%)
`
`19/65 (29%)
`M uitivessei procedure
`
`Procedural time (min)
`79:43
`
`Volume of contrast (ml)
`220:118
`
`Total length of stents implanted (mm)
`
`41:29
`
`Table 2. Target vessels and lesion characteristics.
`
`
`
`17/70 (24%)
`I Left anterior descending artery
`20/70 (29%)
`I Left circumflex artery
`23/70 (33%)
`Right coronary artery
`10/70 (14%)
`
`
`
`I Vein graf
`
`68/70 (97%)
` Type 82/0 lesion
`
`Distal location
`
`
`
`Severe calcification
`16/70 (23%)
`
`
`12/70 (17%)i Chronic total occlusion
`
`
`i
`I i
`
`I Reference vessel diameter (mm)
`30:11.5
`.
`89:13
`I Diameter stenOSis (%J
`
`I Lesion length (mm)
`38:26
`
`I
`
`
`
`
`
`"n;no};grargriaagaa""""""""""""""""""""""""ian;"""""""
`Depth of GuideLiner intu‘oation (mm)
`33:21
`
`41/70 (59%)
`improvement of back-up and facilitated
`stent delivery
`
`More selective contrast injection 9/70 (13%)
`I
`improvement of alignment of the guide
`20/70 (29%)
`I
`
`Success, failures, and complications
`1
`
`Device success
`65/70 (93%)
`Procedural success
`I
`54/70 (91%)
`I
`
`0/70
`
`
`Minor complications
`2/70 (3%)
`Air embolism
`1/70 (1%)
`
`
`Stent dislodgement
`1/70 (1%)
`
`
`
`
`INDICATION FOR GL USE AND PROCEDURAL DETAILS
`
`A11 procedures were carried outwith the “5—in—6” Fr GL device. As shown
`in Figure 3, the pinnary indications for (3L use were to increase back—up
`of the guide catheter; in general to facilitate stent delivery (59%} and to
`improve alignment ofthe guide catheter (29%) (Table 3). In a few patients
`(1 96), the GL was used for selective contrast injection, predonmiantly
`because of dominant Ieft coronary artery (1 CA) and/0r renal impairment.
`There were differences between the application in right coronary artery
`
`
`amen/(i ,fltandfriprrrimi (ii/i). iii/ac (wrists/Jig um achieve/7' using a {ii/(r? 5i? wire.
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`mfg (‘3' with an me’i'erigfm’ clinical {‘92th
`
`(RCA) and LCA mterventions. In the LCA, the GL catheter was used
`regularly to improve the alignment ofthe guide or enhance selective con—
`trast injections, whereas its use in RCA interventions was mainly to
`increase catheter back-up (p=0.024j). An example is shown in Figure 2.
`A 6 Fr guide catheter was used in all wbiects, while radial access was
`chosen in one third of cases. Multivessel procedm’es were performed in
`almost one third of the patients, and there were 17% of chronic "total
`occlusions. Ofall l26 stents implanted 123 (98%) were third-generation
`
`drug-eluting stents (DES). In this registry, we noted a single stent that
`was damaged upon advancement across the metallic collar of the GL;
`damage to the (secondary) guidewirc tip when passing the metallic collar
`of the GL occurred slightly more often (4/70; 6%).
`
`DEVICE SUCCESS AND DEVICE FAILURE
`
`The overall success rate of the GL was 93%. The average depth to
`which the GL was intubated in the proximal target vessels was
`
`33:22 mm (range: 0 Lo l06 mm), however, these generally deep intu—
`bations did not cause any coronary dissections. lhe rate of procedural
`success of the transradial and traiisfeinoral access routes was 95.5%
`
`and 88.4% (p=0.35), respectively, but the power ofthe study was insuf—
`ficient to draw sound conclusions from this comparison. There were
`live device Failures (5/70; 79/6), which are illustrated in Figure 3.
`
`COMPLICATIONS
`
`We noted no major complications or coronary dissections. There
`were two minor complications, which are outlined below. In the
`first case. during PCl of a diffusely diseased RCA in a 53-year-old
`male, the GL was deeply advanced (61 mm intubation depth) to
`increase back—up support and to pass a balloon catheter across the
`heavily calcified distal RCA stenosis. Dining this manoeuvre, some
`air embolism was noted as a result of insufficient venting of the
`wedged GL, which caused a brief phase of stasrs of coronary flow
`that was rapidly resolved. The second minor complication occurred
`during PCI of a long mid lesion in an RCA with “shepherd’s crook”
`anatomy. After predilatation and stenting of the mid RCA, an
`attempt to advance a second stent through the first one was made,
`which turned out to be extremely difficult. To increase support, the
`GL was advanced over both guidewires and the second stent balloon
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`3.as:(m
`as
`
`a:
`
`
`
`noa:
`“I“M
`%
`
`a4
`
`system (stent still urideployed), which led to dislodgenrent of the
`stent from the balloon. Eventually the dislodged stent was crushed
`behind a third stent and was postdilated with high balloon pres—
`sures, leading to a good final angiographic result with an uneventful
`clinical course until the eight—month follow—up.
`
`{Eiseussion
`Good back—up of the guide catheter is crucial for both wiring and
`equipment delivery. The development of guide catheter extension
`systems has further expanded the therapeutic arsenal of the inter-
`ventional cardiologist”. lrrtubation of the guide catheter extension
`system into the target vessel provides enhancement of equipment
`delivery in challenging coronary lesions, and facilitates engage-
`ment in case of difficult takeoff of the coronary ostiurn. Takahashi
`et al demonstrated that a guide catheter extension system provides
`a substantial improvement in back—up supports. The support was
`directly related to the depth of intubation. For example, insertion of
`a 5 Fr guide catheter 15 mm into a 6 Fr catheter doubled the back—
`up support. The guide catheter extension system may be used as
`a tool for deeper intubation of the guide, referred to as “rail—road—
`ing”, as was described in detail by Farooq et a1“. Its use in graft
`interventions is well recognised as aiding graft cannulation and
`enhancing the stability of the guide in the graft ostium. Further
`back—up may be achieved by advancing the extension catheter,
`thereby allowing the guide to back out and down until it rests on the
`aortic valve or contralateral aortic wall (Swan—neck manoeuvre)”.
`And finally, guide catheter extension systems can be used as an
`aspiration device“.
`The 'fwen‘te GuideLiner registry reports on a consecutive series of
`GL applications in 65 patients, treating 70 target vessels with implan-
`tation of 126 stents (98% being third-generation DES). So far, this is
`the largest registry on the use of the GL in routine daily practice.
`Demographics and clinical characteristics of the study population are
`similar to previous all—comers stent studies and our general PCI pop—
`19-25
`ulation
`. However, lesion characteristics differed a lot from the
`general patient population as the ma} ority of target lesions were long
`
`and complex; all but two target lesions (97%) were classified as
`lesion type B2 or C with more than half of them being located dis-
`tally, and the vast majority being at least moderately calcified.
`During the first months, the UL was used as a bailout device in
`challenging cases, when the “old familiar tricks" (e.g., deep—seat—
`ing manoeuvres or use of buddy wires) had failed. However, after
`becoming more familiar with the device, we switched to a more
`upfront use in difficult anatomical situations. in our present series,
`the main indication for GL use was to improve guide support to
`facilitate stent delivery (59%). An illustration is shown in
`Figure 2. However, in one third of the cases the (EL was used to
`improve coaxial alignment of the guide catheter in anatomical sit—
`nations with an abnormal takeoff of the target vessel (e.g., shep-
`ierd’s crook-shaped proximal RCA) or a vertical takeoff of either
`{CA or left main stem. In particular, a vertical offspring of the left
`main stem, as may be seen in young lean patients or patients with
`oulmonary emphysema, bears an increased risk of dissecting the
`eft main stem with a guide catheter. Gentle intubation of the GL
`substantially
`facilitated the
`intervention
`in
`such patients
`(Figure 4). In a small number of patients, the GL was used to per—
`‘orm selective contrast injections for a better visualisation of the
`vessel of interest wrth smaller amounts of contrast; this indication
`~or GL use may be considered in patients with large calibre ves—
`sels, such as a dominant left coronary artery, and an impaired
`renal function, or if an adequate visualisation cannot be achieved
`y other means“.
`The GL may also be useful to facilitate demanding diagnostic cor-
`onary angiographies, which has not been described so far and was
`)ey end the scope of our registry of GL use in PCl patients.
`\levertheless, we would not like to withhold the information that our
`group also used the GL in several demanding cases of diagnostic
`angiogiaphic visualisation of bypass grafts. Figure 5 shows an example
`of a gastroepiploic artery (GEA) graft, visualised both with and
`without use of a GL. It should be emphasised that in case of coronary
`angiography, the operator should refrain from the use of intracoro-
`nary Wires arid devices as much as possible. However, there are
`
`
`
`
`
` ' oft/re fair ”mm (/l and If}. The {Markham Catheter was modify
`hp; 7?;
`Figure 4, fingiogmphie overview of}; wiper! with t; vertical or?
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`Horton! sacrament o/“n’re grading cat/Mei; profiting: gmiie gargantuan in fire {M and good salami": to am): the 1.].
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`gmfl'm (,1 Sdfyziarmoid areafezpafleiai’. Panel], .4. shows vague images (Zr/11th? {51314 grtg‘i‘.
`Figure 5. ff,vziciiz"il‘ioir of}: gastrtszgiz ‘
`”
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`(dimmer?! during 3? gm angiogm {rt/3y 35w) 1'; ears cow's r: Pane? B
`lmlwilié'rigfihiz'nc'c#3342113} qualify aim med iannl’g’p with [he as, .‘
`Gait/fainter (HID catheter: The warm in Panel ('7 is pointed a! the tip rgf'alm (7‘11 catheter:
`
`circumstances in which a graft cannot be properly visualised. Instead
`of accepting a poor visualisation. the use of a guide catheter exten-
`sion system can be considered in order to achieve conclusive angio-
`graphic imaging. It should be used by an mterventional cardiologist
`with great care, and maximum effort should be taken to ensure that
`such manoeuvres do not give rise to a coronary dissection.
`
`SUCCESS RATE, SHORTCOMINGS, AND POTENTIAL
`PROCEDURAL RISK
`
`The success rate of the GL was 93% in our study, which is in agree-
`ment with previously reported smaller case serieslnv‘ilm. Stent dairi—
`age at the site of the metallic collar of the GL occurred in one out of
`126 stents implanted. which was a drug-eluting stent with a nominal
`diameter of 3.5 mm. Others have reported a higher rate of stent dairi—
`age (6%) due to the collar of the le catheter“. Therefore, we dis—
`courage the use of stents with a nominal diameter of4 min or more
`through a “5—in—6” Fr GL catheter. Murphy et a1 recently reported an
`uncommon case of balloon damage at the site of the metallic collar“.
`In addition, secondary (buddy) guidewires can be damaged upon
`advancement when the GL is in place, as reported in our present
`study. The “5-in-6" Fr GL catheter permits the passage of virtually all
`regular balloon catheters, contemporary optical coherence tomogra—
`phy (OCT) catheters, and coronary stems up to a nominal diameter of
`3.5 mm. However, it does not allow the use of larger devices such as
`thrornbectoniy catheters, some intravascular ultrasound (IVUS)
`probes, and simultaneous kissing balloon inflations.
`Although the GL turned out to be generally beneficial with
`a relatively low rate of device failure. we identified some scenar—
`
`in which the usefulness of the GI, may be questionable,
`ios,
`Firstly, a difficult access due to iliac tortuosity may impede the
`advancement of the GL through the mother guide, as was seen in
`one of our patients. Secondly, the proXimal part of the target ves—
`sel should be suitable for intubation of the GL catheter; therefore,
`ostial/very proximal lesions or sharp angles of coronary arteries
`may lead to device failure. as was noted in the majority of our
`cases with device failure.
`
`In general, use of the GL turned out to be safe. No major compli-
`cations were noted. but there were two minor complications with
`favourable outcomes and an otherwise uneventful clinical course.
`
`There was one case of air embolism due to insufficient venting. In
`the second case, a stent was dislodged from the balloon by the tip of
`the GL when advancing the GL over a stent balloon system. Both
`complications could have been avoided, if more care had been
`taken and the instructions of the manufacturer had been followed.
`
`Luna et al15 reported a substantially higher number of cases with
`pressure dairipeiiiiig (57%) during engagement of the GL catheter;
`however, dissimilar to our study, they used a “6—in—7” Fr system in
`the majority of cases.
`
`HOW TO USE THE GUIDELINER AND HOW TO AVOID
`COMPLICATIONS
`Several considerations can be mentioned in order to choose or refrain
`
`from the use of a guide catheter extension. If more back—up of the
`guide catheter is required, the first step can be the use of buddy wires,
`extra stitf wires, or buddy balloons. However. if these measures fail,
`a GL catheter may be considered, which allows the mother guide and
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`LIMITATIONS
`
`
`
`The present registry of a consecutive series of PCI patients treated
`with the use of the “5—in—6” Fr GL provides some “real—life” insight
`into efficacy,
`limitations, and the potential risk of this device.
`Although our patient population is larger than that of all previously
`reported cases and patient series altogether”"18 the population is still
`relatively small. In addition, due to well—known limitations inherent
`o registries, this single centre registry cannot provide the scientific
`evel of insight that might be obtained from a randomised study. Dur-
`ing the course of this registry, use of highly deliverable third-genera-
`
`ion DES in most patients was our standard of carezg, which could
`ave affected our results. We cannot exclude that in cases with
`
`upfront use of the GL, a standard guide catheter or other manoeuvres
`and tricks (cg, deep intubations or buddy wires) could also have led
`0 pfOCfidtlfflI success.
`
`CONCLUSIONS
`
`lse of the GuideLiner catheter resulted in an increased back—up
`support and guide catheter alignment for stent delivery in the pres—
`ence of unfavourable tortuous coronary anatomies and in complex,
`eavily calcified, and often distally located lesions, which other—
`wise may have been considered unsuitable for PCI. The procedural
`success rate of the GL was high without major complications.
`
`FUNDING
`
`This investigator—mitiated study was performed without specific
`funding. The research department received educational and/or
`research grants in the past and has participated in clinical studies
`funded by Abbott Vascular, Biosensor's, Biotronik, Boston Scien—
`tific, Cordis, and Medtronic.
`
`fienttict of interest statement
`C. von Birgelen is a consultant to and has received lecture fees or
`travel expenses from Abbott, Medtronic, and Boston Scientific and
`has received a speaker’s honorarium from Merck Sharp & Dohme.
`All of the other authors have no conflict of interest to declare.
`
`References
`l. Burzotta F, Trani C,Mazzari MA,Morigiardo R, Rebuzzr AG,
`Ruifon A, Niccoli G, Rioridi—Zoccai G, Romagnoli F, Rama/.mlti V,
`Schiavoni G, Crea l7. Use ofa second buddy wire during percutane—
`ous coronary interventions: A simple solution for some challenging
`situations. J Invasive Cordial. 2005;17:171—174.
`2. Hirokami M Saito S, Muto H. Anchoring technique to
`improve guiding catheter support in coronary angioplasty of chronic
`total occlusions. Catheter Cardiovasc Imam 2006;67:366-371.
`3. Peels H0, van Roven AJ, den Heijer P, Tio RA,
`l.ie Kl,
`Crijns HJ. Deep Seating of six French gliding catheters for deliv-
`ery of new PalmaZ-Schatz stents. Catheter Cardz’ovasc Inteiv.
`1996;38:2l0—2l3.
`4. von Sohsten R, 07 R, Marone G, McCormick DJ. Deep intu—
`bation of 6F guiding catheters for transradial coronary interven—
`tions. JI/tvasive Cordial. [998,10 l 98-202.
`
`wires to be left in place. The operator should, however, be convinced
`that the proximal part ofthe target vessel is suitable for intubation. If
`the lesion extends to the proximal segment or if there is sharp angula—
`tion, the use of a guide cameter extension system is generally not
`recommended. Alternatively, the proximal segment may be stented
`first, followed by gentle intubation of the GL catheter and treatment
`of the distal segment (so—called proximal—to—distal stenting). How—
`ever, care should be taken to avoid deformation or longitudinal corn—
`pression of a proximally implanted stentmg. If there is a problem
`with coaxial alignment of the available guide catheters, the operator
`should estimate the risk of performing the procedure with a subopti—
`mal position of the tip of the guide (in case of a simple proximal
`lesion one may continue). However, if substantial back-up is required,
`it appears wise to use a guide catheter extension. This decreases the
`risk of guide—induced dissections and improves the back—up of the
`mother guide. If the patient has an impaired renal function and the
`operator expects to use large amounts of contrast (e.g., in a dominant
`left coronary artery system), a guide caflieter extensron system may
`be considered as a valuable first choice. And finally, if the operator
`intends to treat a bifurcation lesion, it should be realised that a “5 —in—
`6” Fr system does not allow the simultaneous use of two balloons.
`Therefore, a choice should be made to use a larger guide catheter
`extension system (“G-in 7” Fr system or ProxisTM device), remove the
`guide catheter extension system before the kissing procedure, or
`refrain from its use and adhere to usual practice.
`
`A WORD OF CAUTION
`
`lntubation ofthe GL bears the risk of causing a dissection in a prox-
`imal coronary artery and should be performed carefully. If resist—
`ance is encountered when advancing the device, the GL can be
`retrieved into the mother guide and then re-advanced over a balloon
`catheter (to improve alignment) into the target vessel”. After
`advancing the GI. into the vessel, the operator should check the
`coronary pressure waves and verify the presence of adequate, pre—
`served antegrade coronary flow. Since use of the GL reduces the
`size of the working lumen, there is an increased risk of air ernbo—
`lism, which can be diminished by slow advancement and with—
`drawal of the equipment; time should then be taken