Document downloaded from http://www.revespcardiol.org, day 27/04/2012. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
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`484
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`Scientific letters / Rev Esp Cardiol. 2012;65(5):479–488
`
`The GuideLinerW Catheter in Complex Coronary Interventions
`
`Utilizacio´n del cate´ter GuideLinerW en angioplastias coronarias
`complejas
`
`To the Editor,
`
`Stent placement frequently poses considerable difficulty in
`coronary interventions, especially in tortuous or calcified arteries
`and chronic occlusions; this is evidenced by the fact that failed
`stent deployment still occurs in 2.7% to 3.3% of the interventions
`undertaken.1
`In complex angioplasty procedures of this type, different
`to resolve
`the problem of
`strategies have been emerging
`inadequate guiding catheter support, including the use of high-
`support guide wires and techniques involving buddy wires, buddy
`balloons, or anchoring balloons (inflation of an anchoring balloon
`in side branches). Deep intubation of the coronary artery is another
`of the strategies, but is limited by the possible occurrence of the
`dissection of proximal plaques or total occlusion of the vessel
`during maneuvers of this type.
`The GuideLinerW catheter (Vascular Solutions Inc., Minneapolis,
`Minnesota, United States) is a coaxial ‘‘mother and child’’ catheter,
`mounted on a monorail system, that extends the angioplasty
`guiding catheter and enables deep intubation of the coronary
`artery to achieve extra support and improve coaxial alignment. It
`has a distal end of 20 cm, consisting of a flexible extension with a
`radiopaque marker situated 2.7 mm from the tip and a coaxial
`exchange system 20 cm from the tip, joined to a 125-mm compact
`metal hypotube by means of a ring (Fig. 1). The flexible design of
`the catheter and the absence of a distal primary curve permit deep
`and theoretically atraumatic
`intubation of the coronary tree,
`increasing guiding catheter support, which enables selective
`injections and reduces the amount of contrast medium employed.
`In addition, it provides an extension to the guiding catheter that, on
`occasion, makes it possible to gain access to the ostia of hard-to-
`reach coronary arteries or coronary bypass grafts. It is compatible
`with standard guiding catheters (except those with a conical tip)
`and its lumen is 1 Fr smaller than that of the catheter utilized. We
`describe the initial experience with the use of the GuideLinerW in a
`single center.
`The GuideLinerW was employed in 7 complex elective coronary
`interventions. Three of them involved chronic occlusions of right
`coronary artery (including 1 case of complete stent occlusion),
`another 2 were procedures in highly calcified right coronary
`arteries, and the remaining 2 were interventions in circumflex and
`anterior descending coronary arteries. In 2 cases the GuideLinerW
`was used from the start of the procedure as the instrument of
`choice, and in the other 5 when standard measures to increase the
`degree of support had failed.
`sheath
`introducer
`A
`femoral approach using an 8-Fr
`was employed in every case; in 2 of them, the intervention was
`performed with bilateral access for contralateral injections (Fig. 1).
`Rotational atherectomy was carried out in 3 procedures, followed
`by the use of the GuideLinerW to advance the materials used in the
`angioplasty.
`The characteristics of the patients and of the interventions are
`shown in the Table 1.
`In 6 procedures, the GuideLinerW afforded adequate alignment
`of the catheter with the artery; however, in one case, deep vessel
`intubation was not achieved because the advance of the device was
`impeded by a stent implanted at a proximal level. In 4 cases, the
`GuideLinerW was considered key to the success of the intervention
`as it enabled the advance of the angioplasty materials, a maneuver
`that had not been achieved with other techniques. There were no
`complications related to the utilization of the device and the course
`
`of the patients was favorable, with a mean postintervention
`hospital stay of 3.8 days.
`There are few publications on the utilization of this catheter2–5
`and they have not reported complications associated with its use.
`rapid exchange and offers
`Its monorail design permits
`important advantages over
`its predecessors, the
`‘‘five-in-six
`mother and child’’ catheters Heartrail IIW (Terumo Corp., Tokyo,
`Japan), which had a coaxial system that made their utilization
`more demanding.5
`Its use is not recommended in vessels measuring less than
`2.5 mm or in saphenous vein grafts, although concerning the latter,
`the GuideLinerW was
`cases have been published
`in which
`especially useful as it provided good alignment with the graft.6
`For optimal use of this device, the following recommendations
`can be taken into account:
`
`
`
`
`
` The GuideLinerW should be inserted using a guiding catheter over
`a first angioplasty guide wire in such a way that the tip protrudes
`a maximum of 10 cm beyond the guiding catheter tip. Intubation
`of more than 20 cm can result in the introduction of the entire
`GuideLinerW into the coronary artery, a circumstance that could
`complicate
`its withdrawal.
`In addition, the connection to
`the flexible segment should be situated in the straight portion
`of the guiding catheter in order to facilitate the passage of
`devices along it.
` It is recommended that the stents be advanced over the first
`angioplasty guide wire inserted, given that the second guide wire
`may be positioned outside the GuideLinerW and interfere with
`the deployment of the stent.
`
`Despite the small number of cases, we consider that this
`catheter may be highly useful in complex coronary interventions,
`in which it provides extra support that considerably facilitates the
`advance of
`the materials used
`in angioplasty and avoids
`the potential complications associated with more aggressive
`techniques.
`
`A
`
`
`
`C
`
`
`B
`
`D
`
`E
`
`Figure 1. A and B, angioplasties to correct chronic total occlusion of right
`coronary artery involving bilateral access and the GuideLinerW catheter. C,
`selective intubation with GuideLinerW in a highly calcified right coronary
`artery. D and E, diagram.
`
`
`Page 1
`
`Teleflex Ex. 2170
`Medtronic v. Teleflex
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`

`

`Document downloaded from http://www.revespcardiol.org, day 27/04/2012. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
`
`Scientific letters / Rev Esp Cardiol. 2012;65(5):479–488
`
`485
`
`Table 1
`Baseline Characteristics of the Patients in Which the GuideLinerW Was Employed and Description of the Procedure
`
`Age, years
`
`Sex
`
`Logistic EuroSCORE, %
`
`Ventricular dysfunction
`
`Clinical indication
`
`Patient 1
`
`Patient 2
`
`Patient 3
`
`Patient 4
`
`Patient 5
`
`Patient 6
`
`Patient 7
`
`69
`
`M
`
`8
`
`Yes
`
`68
`
`M
`
`15
`
`No
`
`74
`
`F
`
`8
`
`Yes
`
`72
`
`M
`
`30a
`
`Yes
`
`43
`
`M
`
`1
`
`No
`
`45
`
`M
`
`1
`
`No
`
`75
`
`M
`
`11a
`
`Yes
`
`Resting
`angina
`
`Non-Q-wave
`infarction
`
`Positive
`ischemia test
`
`Resting
`angina
`
`Resting
`angina
`
`Positive
`ischemia test
`
`Positive
`ischemia test
`
`CTO RC
`
`CX
`
`Target vessel
`
`LMC-AD
`
`Duration of procedure, min
`
`Fluoroscopy time, min
`
`Contrast medium volume, ml
`
`Length of hospital stay following
`angioplasty, days
`
`60
`
`12.8
`
`130
`
`14
`
`RC
`
`90
`
`39.9
`
`200
`
`2
`
`CTO RC
`
`220
`
`55
`
`230
`
`1
`
`RCb
`
`124
`
`43
`
`200
`
`7
`
`CTO RC
`
`240
`
`118
`
`370
`
`1
`
`180
`
`80
`
`320
`
`1
`
`55
`
`27.4
`
`270
`
`1
`
`AD, anterior descending coronary artery; CTO, chronic total occlusion; CX, circumflex coronary artery; F, female; LMC, left main coronary artery; M, male; RC, right coronary
`artery.
`a Patient no. 4 had chronic renal failure requiring hemodialysis, as well as severe peripheral arterial disease. Patient no. 7 had advanced chronic obstructive pulmonary
`disease.
`b Patient no. 4 had total occlusion of the right coronary artery stent; complete right coronary artery reconstruction was performed in a previous procedure.
`
`Leire Unzue´ ,* Felipe Herna´ ndez, Maria Teresa Vela´ zquez,
`Julio Garcı´a, Agustı´n Albarra´ n, and Javier Andreu
`
`Unidad de Hemodina´mica y Cardiologı´a Intervencionista, Hospital 12
`de Octubre, Madrid, Spain
`
`* Corresponding author:
`E-mail address: leireunzue@yahoo.es (L. Unzue´ ).
`
`Available online 12 October 2011
`
`REFERENCES
`
`series of experience with the Heartrail II catheter. J Invasive Cardiol. 2011;
`23:E43–6.
`2. Mamas MA, Fath-Ordoubadi F, Fraser DG. Distal stent delivery with Guideliner
`catheter: first
`in man experience. Catheter Cardiovasc
`Interv. 2010;76:
`102–11.
`3. Kumar S, Gorog DA, Secco GG, Di Mario C, Kukreja N. The GuideLiner ‘‘child’’
`catheter for percutaneous coronary intervention - early clinical experience.
`J Invasive Cardiol. 2010;22:495–8.
`4. Rao U, Gorog D, Syzgula J, Kumar S, Stone C, Kukreja N. The GuideLiner ‘‘child’’
`catheter. EuroIntervention. 2010;6:277–9.
`5. Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the Heartrail III
`catheter as a stent delivery catheter following failure of conventional techniques.
`Catheter Cardiovasc Interv. 2008;71:358–63.
`6. Wiper A, Mamas M, El-Omar M. Use of the GuideLiner catheter in facilitating
`coronary and graft intervention. Cardiovasc Revasc Med. 2011;12:68.5–7.
`
`1. Hynes B, Dollard J, Murphy G, O’Sullivan J, Ruggiero N, Margey R, et al. Enhancing
`back-up support during difficult coronary stent delivery: single-center case
`
`doi: 10.1016/j.rec.2011.08.003
`
`Variegate Porphyria and Atrial Fibrillation: Acute Attack
`Induced by Propafenone
`
`Porfiria variegata y fibrilacio´n auricular: ataque agudo inducido
`por propafenona
`
`To the Editor,
`
`Porphyrias are metabolic bone diseases caused by deficiencies of
`enzymes involved in heme biosynthesis. Acute hepatic porphyrias
`(AHPs) can present as episodes of acute porphyria with abdominal
`pain, autonomic dysfunction
`(hypertension,
`tachycardia, and
`gastrointestinal disorders), and deep motor neuropathy. Variegate
`porphyria (VP) is a type of autosomal dominant hepatic porphyria
`secondary to protoporphyrinogen oxidase activity deficiency that
`can present acute neurological manifestations and/or cutaneous
`photosensitivity. Drugs are the factors most commonly implicated
`as triggers of acute attacks. We describe a patient with VP who
`received class
`Ic antiarrhythmic agents for paroxysmal atrial
`fibrillation (AF) and presented with
`an acute episode of
`porphyria, which consisted of acute abdomen and syndrome of
`inappropriate antidiuretic hormone secretion (SIADH).
`Our patient was a 40-year-old male with a history of VP
`diagnosed by skin biopsy and elevation of blood aminolevulinic
`
`acid and porphobilinogen and fecal protoporphyrins who had a
`relative with the same condition but no activity to date. The
`patient experienced various episodes of paroxysmal AF. He was
`initially treated with flecainide but later switched to propafenone
`due to digestive intolerance. One week after initiating propafe-
`none therapy, the patient began to have abdominal pain and
`bloody urine. He came to the emergency room and was referred
`to the internal medicine department for further study. During the
`examination, only the diffuse abdominal pain without accom-
`panying signs of peritonism was relevant. The laboratory workup
`showed normal kidney function, GOT, 41 U/L; GPT, 43 U/L;
`alkaline phosphatase, 50 IU/L; GGT, 50 IU/L; LDH, 539 IU/L;
`sodium, 111 mEq/L; and plasma osmolarity, 231 mOsm/L. The
`urinary tests showed urinary sodium of 109 mEq/L and elevated
`osmolarity. The heart, thyroid, and adrenal panels were normal.
`An abdominal ultrasound showed no relevant findings; the
`Hoesch test was positive. Porphyrin and porphyrin precursor
`determination in urine showed an increase in porphobilinogen,
`as well as delta-aminolevulinic acid, coproporphyrin, and
`in stools. Based on these findings and the
`protoporphyrins
`normalization of biochemical and clinical parameters once
`propafenone was discontinued, an attack of propafenone-
`induced VP with SIADH as a form of expression was diagnosed.
`Hematin (5 mg/kg/day) was given for 4 consecutive days, and
`
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`Page 2
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`Teleflex Ex. 2170
`Medtronic v. Teleflex
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`