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`Home > Guideliner Microcatheter to Improve Back-Up Support During a Complex Coronary Stenting Procedure Through a Tortuous Lefl Internal Mammary Grail
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`Guideliner Microcatheter to Improve Back-Up Support
`During a Complex Coronary Stenting Procedure Through a
`Tortuous Left Internal Mammary Graft
`By hmpeditor
`Created 03/27/2012 - 16:14
`Agril 2012 [1]
`
`Guideliner Microcatheter to Improve Back-Up Support During a Complex
`Coronary Stenting Procedure Through a Tortuous Left Internal Mammary Graft
`
`0 Tue, 3/27/12 - 4:14pm
`- 0 Comments
`
`Section:
`Online Exclusive
`Issue Number: Volume 24 - Issue 4 - Agril 2012 [2]
`Author(s):
`
`Chan—il Park, MD, Stephane Noble, MD, Robert F. Bonvini, MD
`
`ABSTRACT: Back-up support during percutaneous coronary interventions (PCI) is one of the keys for successful intervention.
`Extra back-up support guiding catheters, deep intubation, buddy wires, and other more complex techniques are usually used to
`improve this support. Left anterior descending (LAD) artery PCI through the left internal mammary artery (LIMA) are rarely
`performed because many operators feel reluctant to instrument a disease-free LIMA graft risking iatrogenic complications by
`passing wire, balloons, and stents to the diseased distal LAD.
`
`Improving back—up support during LIMA—LAD PCIs is often challenging because in this particular setting the distance between the
`LAD lesion and the guiding catheter is exceedingly long.
`
`We report a case of a challenging ROI of the LAD through a patent and disease-free LIMA graft. After multiple failed attempts to
`cross the LAD lesion with conventional stent deployment techniques, we successfully finished the stenting procedure using the
`Guideliner microcatheter (Vascular Solutions) as a guiding extension through the LIMA graft. With this case, we illustrate that this
`microcatheter dramatically improves the back-up support, allowing stent deployment also in very difficult settings as in tortuous
`LIMA grafts.
`
`Key words: Guideliner microcatheter, coronary artery bypass graft, back-up support, percutaneous coronary intervention
`
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`J INVAS/VE CARD/0L 2012;24(4):E77-E79
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`Percutaneous coronary interventions (PCI) are most commonly associated with stent implantations. In order to safely and rapidly
`reach and cross the target coronary lesion, the back-up support of the adopted guiding catheter is one of the keys of success.
`Nevertheless, in case of important tortuosity and/or calcifications of the coronary vessels, stent delivery at the target lesion may be
`challenging, despite adequate lesion preparation with balloon pre—dilataljon.1
`
`Left anterior descending (LAD) artery PCI through the left internal mammary artery (LIMA) are rarely performed because these
`arterial bypass grafts are associated with good long-term patency rates and many operators feel reluctant to instrument a disease-
`free LIMA graft, risking iatrogenic complications by passing wire, balloons, and stents to the diseased distal LAD.2’3 We report a
`case of a challenging LAD-PCI through a patent, tortuous, and disease-free LIMA graft, underlying the technical issues adopted in
`order to improve the back—up support of the guiding catheter in this particular guiding—lesion long—distance setting.
`
`Case Report
`
`[31A 65-year-old male with previous 3-time coronary artery bypass grafting in 1995 was admitted for unstable angina.
`Coronary angiogram showed native ooronanl occlusions at the level of proximal LAD (Figure ’l) and proximal right
`coronary artery. The left main and a previously stented proximal left circumflex artery were disease-free, while a
`large intermediate branch, unsuccessfully treated in 2006, was also occluded (during that PCI a coronary wire broke
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`Guideliner Microcatheter to Improve Back-Up Support During a Complex Coronary Stent... Page 2 of 3
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`in this intermediate branch) (Figure ’l). The LIMA graft to mid LAD was free of lesions but the mid LAD showed a
`long, calcified, and tight stenosis (Figures 2A and 25). The 2 saphenous vein grafts, one anastomosed to the first obtuse marginal
`branch and the other one to the distal RCA, were both chronically occluded.
`
`[4]Coronary angiography, as well as the mid LAD PCI, was then attempted using a left radial approach. The LIMA
`ostium was easily engaged with a 6 Fr IMA guiding catheter (Medtronic Vascular). The distal LAD was wired (BMW,
`Abbott Vascular), pre-dilated [Maverick 2 Monorail 2.5/20 mm (Boston Scientific)], and stented [Resolute Integrity 3.0
`mm x 26 mm (Medtronic)]. After successful mid-LAD stenting, a type C dissection distal to the stent was observed
`__
`,,
`(Figure 3). Despite the placement of an extra—support buddy wire [GALEO ES 0.014" (Biotronik)] and several stent
`post-dilatation with non-compliant balloons [Pantera Leo 3.0 mm x 15 mm (Biotronik)], it was not possible to deliver a second stent
`to cover the distal dissection. Neither 2 different drug-eluting stents [RESOLUTE Integrity 2.5/14 mm (Medtronic) lXience Prime
`2.5/12 mm stent (Abbott Vascular)] nor a smaller and shorter bare metal stent [PRO—kinetic 2.25/9 mm (Biotronik)] were able to
`cross the previously implanted stent.
`
`
`
`,,
`a
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`[srlndeed, the inability to cross the first stent was mainly due to angulation at the site of the implanted stent (inducing
`significant friction between the stents' struts) and the lack of back—up support through the long and tortuous LIMA
`graft. Although deep intubation of the 6 Fr IMA guiding catheter was technically feasible thanks to the adopted left
`transradial approach, this maneuver was deemed too risky, especially if considering that the LIMA graft and the LAD
`also gave collaterals to the right coronary artery territory.
`
`[siAt this moment, the only remaining option to improve the back-up support was to use a dedicated guide-extension
`microcatheter. The Guideliner Microcatheter (Vascular Solutions), was easily advanced (ie, telescoping technique)
`through the LIMA and directjy placed in the previously implanted stent at the angulation site (Figure 4). With this
`maneuver, the back-up support of the entire system improved dramatically, and allowed without any further friction or .
`resistance the implantation of the Xience stent, finally successfully sealing the LAD dissection (Figure 5). Final
`angiographic assessment once the wires and the Guideliner were retrieved showed a patent LIMA graft without any sign of spasm
`or iatrogenic complications.
`
`
`
`Discussion
`
`mBack-up support during PCI is one of the cornerstones for a successful intervention. Extra back-up support guiding
`catheters,4 deep intubation,5 buddy wires,6 anchoring balloon technique,7 or a telescoping approach with a mother
`and child techniques'10 are the most common maneuvers used to improve this support.
`
`LAD PCI through LIMA grafts must be performed vew carefully to avoid iatrogenic complications, such as LIMA’s
`spasms or extensive dissections, which may be challenging to handle correctly.3 “’12 Furthermore, it frequently occurs that the
`LIMA graft is the last remaining patent conduit, suggesting that any type of complications occurring in this vessel may have
`dramatic consequences. These issues, associated with a poor backup support secondary to the LIMA tortuosity, are probably the
`main causes why LAD PCls through the LIMA graft have been rarely reported in the literature.“14
`
`
`
`Improving back-up support during LIMA-LAD PCIs is challenging, especially because the distance between the LAD lesion and the
`guiding catheter remains exceedingly long. Moreover, as illustrated in our case, the additional difficulty to cross a newly deployed
`stent due to the important stent struts' friction may finally increase the risk of accidental stent loss in the vessel.15
`
`Mamas et al recently reported the successful use of the Guideliner microcatheter for stent delivery via transradial approach after
`failure of conventional techniques.16 This catheter, available in different sizes (from 5-in-6, 6-in-7, and 7-in-8 Fr), is a flexible coaxial
`microcatheter used as a guide extension. Although the Guideliner microcatheter should not be extended more then 10 cm outside
`the guiding catheter, in our case the distance between the guiding catheter and the lesion was too long to follow this safety
`manufacture recommendation.
`
`This dedicated microcatheter, with very good crossing profile and soft and flexible distal tip, is usually used through standard 6 Fr
`guiding catheters. It is used mostly for bail—out situations for complex PCI, where usual stenting delivery techniques have failed.
`
`The main difference compared to the Heartrail catheter (Terumo Corp.), which is used for the same back—up support improvement,
`is that the Guideliner catheter uses a monorail technology, remaining easier to handle without requiring long or extension wires. It
`also allows safer contrast dye injection or back bleeding through the guiding catheter, thus reducing the risk of accidental air
`embolism or catheter thrombosis. Additionally, with the over—the—wire Terumo Heartrail catheter, only 8 cm of guiding extension are
`possible, suggesting that the Guideliner, which may be advanced much more than the recommended 10 cm, is more suitable
`especially in cases where a very important guide—extension is necessary (eg, through the LIMA graft).
`
`Several reports described the use of the Guideliner microcatheter in challenging PCI cases. However, to the best of our
`knowledge, this is the first case reporting the use of this microcatheter through a tortuous LIMA graft. This “mother and child“
`strategy helped to seal an iatrogenic dissection difficult to reach without injuring the most important remaining open vessel.
`
`Conclusion. When conventional stent delivery and deployment techniques fail, the “mother and child" technique with the
`Guideliner microcatheter dramatically improves back-up support. If used carefully, this microcatheter represents a precious tool to
`successfully perform complex PCI in very calcified or tortuous vessels as described in our case of PCI through a LIMA graft.
`
`Refe ren ces
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`http://Www.invasivecardiologycom/print/3251
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`Guideliner Microcatheter to Improve Back-Up Support During a Complex Coronary Stent... Page 3 of 3
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`1. Nikolsky E, Gruberg L, Pechersky S, et al. Stent deployment failure: reasons, implications, and short— and long-term
`outcomes. Catheter Cardiovasc Interv. 2003;59(3):324—328.
`2. Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg. 2004;77
`(1 ):93—101.
`3. Suresh V, Evans 8. Successful stenting of stenotic lesion and spontaneous dissection of left internal mammary artery graft.
`Heart. 2007;93(1):44.
`4. Di Mario C, Ramasami N. Techniques to enhance guide catheter support. Catheter Cardiovasc Interv. 2008;72(4):505-512.
`5. Bartorelli AL, Lavarra F, Trabattoni D, et al. Successful stent delivery with deep seating of 6 French guiding catheters in
`difficult coronary anatomy. Catheter Cardiovasc Interv. 1999;48(3):279-284.
`6. Jafary FH. When one won't do it, use two-double "buddy" wiring to facilitate stent advancement across a highly calcified
`artery. Catheter Cardiovasc Interv. 2006;67(5):721—723.
`7. Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during advancement of a balloon in
`coronary angioplasty: the anchortechnique. Catheter Cardiovasc Interv. 2003;59(4):482—488.
`8. Takahashi S, Saito S, Tanaka S, et al. New method to increase a backup support ofa 6 French guiding coronary catheter.
`Catheter Cardiovasc Interv. 2004;63(4):452-456.
`9. Mamas MA, Eichhofer J, Hendry C, et al. Use of the Heartrail ll catheter as a distal stent delivery device; an extended case
`series. Eurolntervention. 2009;5(2):265—271.
`10. Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use ofthe Heartrail lll catheter as a stent delivery catheterfollowing
`failure of conventional techniques. Catheter Cardiovasc Interv. 2008;71(3):358—363.
`11. Zanchetta M, Pedon L, Rigatelli G, Olivari Z, Zennaro M, Maiolino P. Pseudo—lesion of internal mammary artery graft and left
`anterior descending artery during percutaneous transluminal angioplasty — a case report. Angiology. 2004;55(4):459-462.
`12. Wong P, Rubenstein M, lnglessis l, Pomerantsev E, Ferrell M, Leinbach R. Spontaneous spiral dissection ofa LIMA—LAD
`bypass graft: a case report. J Inten/ Cardiol. 2004;17(4):211-213.
`13. Zavalloni D, Rossi ML, Scattlirin M, et al. Drug-eluting stents for the percutaneous treatment of the anastomosis of the left
`internal mammary graft to left anterior descending artery. Coron Artery Dis. 2007;18(6):495-500.
`14. Kockeritz U, Reynen K, Knaut M, Strasser RH. Results of angioplasty (with or without stent) at the site of a narrowed
`coronary anastomosis of the left internal mammary artery graft or via the internal mammary artery. Am J Cardiol. 2004;93
`(12):1531—1533.
`15. Cantor WJ, Lazzam C, Cohen EA, et al. Failed coronary stent deployment. Am Heart J. 1998;136(6):1088—1095.
`16. Mamas MA, Fath-Ordoubadi F, Fraser DG. Distal stent delivery with Guideliner catheter: first in man experience. Catheter
`Cardiovasc Interv. 2010;76(1):102—111.
`
`From the Division of Cardiology, Department of internal medicine, Geneva University Hospitals, Switzerland.
`Disclosure: The authors have completed and returned the lCMJE Form for Disclosure of Potential Conflicts of Interest. The authors
`report no conflicts of interest regarding the content herein.
`Manuscript submitted August 4, 2011, provisional acceptance given September 6, 2011, final version accepted November 10,
`2011.
`Address for correspondence: Dr. Robert F. Bonvini, Division of Cardiology, Geneva University Hospitals, 4, rue Gabrielle-Penet—
`Gentil, 1211 Geneva 14, Switzenand. Email: RobertBonvini hcu e.ch [a]
`
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