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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
`Aoril 2012 ty
`
`Guideliner Microcatheter to Improve Back-Up Support During a Complex
`Coronary Stenting Procedure Through a Tortuous Left Internal Mammary Graft
`
`¢ Tue, 3/27/12 - 4:14pm
`* 0 Comments
`
`Section:
`Online Exclusive
`Issue Number: Volume 24 - Issue 4 - April 2012 14
`Author(s):
`
`Chan-il Park, MD, Stephane Noble, MD, Robert F. Bonvini, MD
`
`ABSTRACT: Back-up support during percutaneous coronaryinterventions (PC]) 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 throughtheleft internal mammaryartery (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 PCls is often challenging becausein this particular setting the distance between the
`LAD lesion and the guiding catheter is exceedingly long.
`
`We report a case of a challenging PCI of the LAD through a patent and disease-free LIMA graft. After multiple failed attempts to
`cross the LADlesion with conventional stent deployment techniques, we successfully finished the stenting procedure using the
`Guideliner microcatheter (Vascular Solutions) as a guiding extension through the LIMAgraft. With this case, weillustrate that this
`microcatheter dramatically improves the back-up support, allowing stent deploymentalso in very difficult settings as in tortuous
`LIMAgrafts.
`
`Key words: Guideliner microcatheter, coronary artery bypass graft, back-up support, percutaneous coronary intervention
`
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`J INVASIVE CARDIOL 2012;24(4):E77-E79
`
`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-dilatation.'
`
`Left anterior descending (LAD) artery PCI through theleft internal mammary artery (LIMA) are rarely performed because these
`arterial bypass grafts are associated with good long-term patency rates and manyoperatorsfeel reluctant to instrument a disease-
`free LIMA graft, risking iatrogenic complications by passing wire, balloons, and stents to the diseased distal LAD.2* Wereport a
`case of a challenging LAD-PCl through a patent, tortuous, and disease-free LIMA graft, underlying the technical issues adopted in
`orderto improve the back-up support of the guiding catheterin this particular guiding-lesion long-distancesetting.
`
`Case Report
`
`A 65-year-old male with previous 3-time coronary artery bypass grafting in 1995 was admitted for unstable angina.
`Coronary angiogram showed native coronary occlusions at the level of proximal LAD (Figure 1) 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 1). The LIMA graft to mid LAD wasfree of lesions but the mid LAD showed a
`long, calcified, and tight stenosis (Figures 2A and 2B). The 2 saphenousvein grafts, one anastomosedto thefirst obtuse marginal
`branch and the other one to the distal RCA, were both chronically occluded.
`
`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 (Mectronic)]. After successful mid-LAD stenting, a type C dissection distal to the stent was observed
`nee
`(Figure 3). Despite the placementof 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 (Bictronik)], 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) / Xience 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.
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`|
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`tlndeed, the inability to cross the first stent was mainly due to angulation at the site of the implanted stent (inducing
`significantfriction 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.
`
`At 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 anddirectly 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 furtherfriction or |
`resistance the implantation of the Xience stent, finally successfully sealing the LAD dissection (Figure 5). Final
`angiographic assessmentonce the wires and the Guideliner were retrieved showed a patent LIMA graft without any sign of spasm
`or iatrogenic complications.
`
`
`
`Discussion
`
`t7Back-up support during PCI is one of the cornerstones for a successful intervention. Extra back-up support guiding
`catheters,* deep intubation,® buddy wires,° anchoring balloon technique,’ or a telescoping approach with a mother
`and child technique*'° are the most common maneuvers used ta improve this support.
`
`LAD PCI through LIMA grafts must be performed very carefully to avoid iatrogenic complications, such as LIMA’s
`spasmsor extensive dissections, which may be challenging to handle correctly.°:'':'? Furthermore, it frequently occurs that the
`LIMAgraft 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 LIMAtortuosity, are probably the
`main causes why LAD PCls through the LIMA graft have been rarely reported in theliterature. '>"4
`
`
`
`Improving back-up support during LIMA-LAD PCls is challenging, especially because the distance between the LAD lesion and the
`guiding catheter remains exceedingly long. Moreover, asillustrated in our case, the additional difficulty to cross a newly deployed
`stent due to the important stentstruts’friction may finally increase the risk of accidental stent loss in the vessel."°
`
`Mamaset al recently reported the successful use of the Guideliner microcatheter for stent delivery via transradial approach after
`failure of conventional techniques. © 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 toa 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 havefailed.
`
`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 LIMAgraft. 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 techniquesfail, 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.
`
`References
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`Guideliner Microcatheter to Improve Back-Up Support During a Complex Coronary Stent... Page 3 of 3
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`15. Cantor WJ, Lazzam C, Cohen EA,etal. 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, Departmentof internal medicine, Geneva University Hospitals, Switzerland.
`Disclosure: The authors have completed and returned the I[CMJE 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, 2077, final version accepted November70,
`20117.
`Address for correspondence: Dr. Robert F. Bonvini, Division of Cardiology, Geneva University Hospitals, 4, rue Gabrielle-Perret-
`Gentil, 1211 Geneva 14, Switzerland. Email: Robert.Bonvini@hcuge.ch ja
`
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`Links:
`[1] http://www.invasivecardiology.com/issue/3222
`[2] http:/Avww.invasivecardiology .com/content/volume-24-issue-4-april-2012
`[3] http:/Avww.invasivecardiology .com/files/16%20Park%200E_E77_Fig%201.png
`[4] http:/Avwww.invasivecardiology .com/files/16%20Park%200E_E77_Fig%202.png
`[5] http:/Avwww.invasivecardiology .com/files/16%20Park%200E_E77_Fig%203.png
`[6] http:/Avww.invasivecardiology .com/files/16%20Park%200E_E77_Fig%204.png
`[7] http:/Avww.invasivecardiology .com/files/16%20Park%200E_E77_Fig%205.png
`[8] mailto:Robert.Bonvini@hcuge.ch
`[9] http:/Awew.invasivecardiology.com/printmail/3251
`[10] http:/Awww.invasivecardiolagy .com/print/3251
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`http://wwwinvasivecardiology.com/print/325 1
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