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`GUIDELINER® CATHETER
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`GuideLiner Catheter Facilitates
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`Treatmentof Calcific Ostial
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`Circumflex Artery despite Sever
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`atroflexion
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`PHYSICIAN
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`Barry S. Weinstock, MD, FACC
`South Lake Hospital, Clermont, Florida
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`PRESENTATION
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`The patient is a woman with extensive cardiovascular history
`including prior CABG,porcine aortic valve replacement,
`chronic atrial fibrillation with AV node failure and subsequent
`permanent pacemaker placement. She also has hypertenstion,
`diabetes and a history of stroke. Due to severeleft hip pain
`from degenerative joint disease, she was electively admitted
`for total hip arthroplasty. Post-operatively, she developed
`congestive heart failure and cardiac enzymes were consistent
`with a small peri-operative myocardial infarction. Cardiac
`catheterization was advised for further evaluation of her
`cardiac status.
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`INITIAL FINDINGS
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`The patient underwent diagnostic catheterization (Figure 1)
`which demonstrated a patent left main coronary artery without
`significant disease. The left anterior descending artery had
`severe disease proximally with competitive flow from a bypass
`graft noted distal to the origin of a patent diagonal branch,
`whichitself had severe ostial segment stenosis af 80-90%.
`Theleft circumflex artery had severe proximal tortuosity with
`retroflexion and a critical 95% stenosis at the origin followed
`by moderately severe disease proximally. A large 1st obtuse
`marginal branch had 70% proximal stenosis while a small 2nd
`obtuse marginal branch had 90% ostial segmental stenosis.
`The RCA had diffuse disease. The LIMA graft to the LAD was
`normal but all of the saphenous vein grafts were occluded. LV
`function was remarkably well preserved with EF of 55% with no
`significant wall motion abnormality. The culprit lesion for her
`MI was thought to bethe critical ostial left circumflex stenosis
`and the patient was referred for intervention.
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`TREATMENT
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`The ostial circumflex stenosis was approached using a 7F
`XB 3.5 guide catheter and the patient was anti-coagulated
`with bivalirudin. The circumflex was initially wired using a
`0.014" Hi-Torque Whisper extra-support guidewire. The ostial
`stenosis was dilated using a 3.0 x 15mm Trek® PTCA balloon.
`A Promus® 4.0 x 28mm drug-eluting stent was inserted, but
`could be advancedonly partially into the circumflex despite
`aggressive guide catheter positioning. The stent was removed
`and additional angioplasty was performed using a 3.5 x 20mm
`Apex® balloon catheter.
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`(continued on back)
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` TREATMENT (CONTINUED)
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`A second 0.014” CholCE® PT Extra Support guidewire was
`delivered and the stent was re-advanced over the CholCE
`PT wire. Again, it was not possible to pass the stent into the
`circumflex despite “deep-throating” the guide catheter. The
`first guidewire was removed, and a 7F-compatible GuideLiner
`was advanced without difficulty to the proximal circumflex
`artery. The 4.0 x 28mm stent was then advanced easily into
`the circumflex and the GuideLiner was removed. The stent
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`was positioned at the ostium of the vessel and deployed. The
`1st OM branchwasthendilated using a 3.0 x 20mm Apex
`angioplasty balloon catheter which resulted in a moderate
`dissection. An attempt was made to pass a 3.0 x 23mm
`Promus stent into the OM branch but the stent would not
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`pass through the ostial circumflex stent due to interaction
`with the stent struts. The stent was removed and the
`GuideLiner was re-advanced to the mid-circumflex artery. The
`3.0 x 23mm Promus stent was then easily advanced into the
`OM branch and deployed.
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`Additional views of the left main coronary artery revealed
`mid-distal dissection, likely due to aggressive “deep-throating”
`of the guide catheter. The GuideLiner was re-advanced to
`the proximal circumflex and a 4.0 x 18mm Promus stent
`was advancedto the left main coronary artery with overlap
`distally into the ostial circumflex stent and deployed. The
`GuideLiner was removed and the left main artery and ostial
`/ proximal circumflex were post-dilated using a 5.0 x 12mm
`NC Quantum™Apex balloon catheter. Final angiography
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` confirmed excellent angiographic results in the left main,
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`circumflex and first OM branch (Figure 2). The severe disease
`at the ostium of the small second OM branch wasnottreated.
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`SUMMARY
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`This patient had failure of all but one bypass graft and was
`extremely close to acutely occluding a large circumflex
`artery atits origin. The vessel's tortuosity, retroflexion and
`calcification combined to make stenting virtually impossible,
`despite use of a very strong guide catheter position and
`two extra-support wires. Using the GuideLiner device, it was
`possible to stent the ostial / proximal circumflex, a large OM
`branch after a balloon
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`angioplasty-induced dissection, and the protected left main
`coronaryartery with highly important overlap ofthe ostial
`circumflex stent. This challenging case highlights the utility
`of the GuideLiner, a device which clearly was the difference
`between this procedure’s failure and success.
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`Barry S. Weinstock, MD, FACC
`‘
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`Dr. Weinstock trained at Yale School of Medicine
`before completing his residencyin internal medicine
`at the Hospital of the University of Pennsylvania.
`He completed his cardiology fellowship at Cedars-
`Sinai Medical Center and has been in practice as an
`interventional cardiologist since 1993. He currently
`practices with Mid-Florida Cardiology Specialists in
`Orlando and performs interventional procedures at
`three hospitals in the central Florida area.
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`GuideLiner catheters are intended to be used in conjunction with guide catheters to access discrete regions of the coronary
`and/or peripheral vasculature, and to facilitate placement and exchangeof guidewires and other interventional devices.
`Please see theInstructions for Use fora completelisting of the indications, contraindications, warnings and precautions.
`CAUTION:Federal law (U.S.A.) restricts this device to sale by or on the orderof a physician.
`GuideLineris a registered trademark of Vascular Solutions,Inc.
`All other trademarks and registered trademarks are property of their respective owners.
`©2016 Vascular Solutions,Inc.All rights reserved. ML2411 Rev. B 10/16
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`a
`ascular
`SOLUTIONS
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`Vascular Solutions,Inc.
`6464 Sycamore Court North
`Minneapolis, Minnesota 55369 USA
`CustomerService:
`United States: 888.240.6001
`International: (001) 763.656.4298
`customerservice@vasc.com
`www.vasc.com
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