Case Report
`
`Am Heart Hosp J. 2011;9(1):44–7
`
`Angiographic Success and Successful
`Stent Delivery for Complex Lesions Using
`the GuideLiner™ Five-in-six System—
`A Case Report
`
`Anouska Moynagh, MD,1 Philippe Garot, MD, FESC,2 Thierry Lefèvre, MD, FSCAI, FESC3
`and Yves Louvard, MD, FSCAI3
`
`In this report, we describe two cases of transradial intervention of chronic total occlusions assisted by the GuideLiner catheter when
`the guide catheter support was suboptimal. This novel coaxial system can provide additional support for more complex lesions and,
`in our cases, allowed the procedure to be completed via the transradial approach rather than having to change to transfemoral access.
`
`The transradial approach (TRA) is emerging as a
`
`successful method for coronary intervention. It
`provides the additional benefits of earlier
`ambulation, a reduction in staff workload, and, most
`importantly, a reduction in the rate of access site
`complications, when compared with the transfemoral
`approach (TFA).1–5 However, it also has limitations. Owing
`to the smaller size of the radial artery, the choice of
`guiding catheter (GC) size is limited, with the maximal
`acceptable diameter being 6 Fr in the majority of cases and
`as a result back up support is compromised.6 A number of
`techniques have been used in order to try to improve the
`support.7–11 Recently, the ‘mother-and-child’ technique,
`using a five-in-six system, has emerged as a powerful tool
`to increase back-up support.11
`
`The GuideLiner™ (Vascular Solutions, Inc., Minneapolis,
`MN) (see Figure 1 and 2) catheter is a new coaxial mother-
`and-child guide extension. After crossing the lesion with a
`conventional guide wire (GW), the GuideLiner is used as
`an inner catheter and inserted inside the 6 Fr GC, creating
`a mother-and-child system, and can be used to intubate
`the coronary artery. This improves the back-up support
`and allows selective deep intubation in difficult coronary
`cases enabling easier balloon and/or stent crossing.11–13
`
`In this report we show our first experiences of the
`GuideLiner catheter in two consecutive cases of chronic
`total occlusions of the right coronary artery in which the
`device was able to solve the technical difficulties associated
`with these complex procedures.
`
`Case Report
`Case One
`A 53-year-old man presented with class two stable angina.
`Cardiovascular
`risk
`factors
`included hypertension,
`dyslipidemia, and a history of smoking. Coronary
`angiography revealed a chronic total occlusion (CTO) of the
`mid right coronary artery (RCA) with collateralisation from
`the left system. Subsequent cardiac magnetic resonance
`imaging (MRI) revealed inferolateral ischemia with viability
`in this territory. The decision was made to proceed with
`percutaneous coronary intervention (PCI) of the RCA.
`
`PCI was performed through the right TRA using a 6 Fr
`Judkins Right (JR4.0, Launcher) GC, with the left TRA being
`used for contralateral injections. The origin of the RCA was
`anomalous and difficult to engage with subsequent poor
`GC support and difficult GW manipulation (see Figure 3).
`The GuideLiner catheter was inserted into the 6 Fr GC, to
`obtain better back-up support. After deep intubation of the
`
`• Correspondence: Yves Louvard, MD, FSCAI, Institut Hospitalier Jacques Cartier, 6 rue du Noyer Lambert, 91300 Massy, France. E: y.louvard@icps.com.fr
`
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`Angiographic Success and Successful Stent Delivery for Complex Lesions Using the GuideLiner™ Five-in-six System
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`Case Report
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`Figure 1: GuideLiner™ Catheter
`
`Figure 3: Case One
`
`20 cm rapid exchange section
`
`White positioning markers at 95 cm (single)
`and 105 cm (double) to assist in placement
`through the guide
`
`Radiopaque marker
`located 0.105º from tip
`
`Rapid exhange
`transition
`
`Figure 2: The GuideLiner™ Catheter Within the Guiding
`Catheter, Used to Intubate the Right Coronary Artery
`
`GuideLiner just proximal to the occlusion, and using a
`microcatheter (Finecross, Terumo, Japan), a GW (Fielder,
`Asahi Intecc, Japan) was successfully passed through the
`occlusion to the distal vessel. The lesion was predilated
`with a 1.5 x 15 mm balloon (see Figure 3). A 4 x 23 mm
`stent was easily passed and deployed with an excellent
`angiographic result (see Figure 3).
`
`Case Two
`A 56-year-old man with a history of previous coronary artery
`bypass surgery presented with new onset exertional dyspnea.
`His cardiac risk factors included hyperlipidemia and previous
`smoking. He had previously undergone PCI to the distal RCA,
`posterior descending artery (PDA) and posterior left
`ventricular
`(PLV) vessels 10 years prior. Coronary
`angiography revealed severe disease involving the left anterior
`descending and circumflex arteries with patency of both right
`and left internal mammary arteries to these vessels. The RCA
`was ungrafted and was occluded in its distal segment at the
`level of the previous bare metal stent (BMS) (see Figure 4).
`
`A cardiac MRI was performed and showed ischemia
`and viability of the inferior wall of the left ventricle.
`
`A
`
`B
`
`C
`
`A: Left anterior oblique projection showing occlusion of the mid right
`coronary artery and poor guiding catheter support. B: Balloon predilatation of
`the mid right coronary artery using deep insertion of the GuideLiner™
`catheter through the 6 Fr GC. Arrow shows the distal tip of the GuideLiner
`catheter and arrowhead shows tip of 6 Fr guiding catheter. C: Final
`angiographic result.
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`Summer 2011
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`Angiographic Success and Successful Stent Delivery for Complex Lesions Using the GuideLiner™ Five-in-six System
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`Case Report
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`Figure 4: Case Two
`
`The American Heart Hospital Journal
`
`A
`
`B
`
`C
`
`D
`
`A: Left anterior oblique projection showing occlusion of the distal right coronary artery. B: Left anterior oblique view of right coronary artery poor support
`with the AL1 guiding catheter. C: Balloon pre-dilatation of the distal right coronary artery using deep insertion of the GuideLiner™ catheter through the 6 Fr
`guiding catheter. Arrow shows the distal tip of the GuideLiner catheter and arrowhead shows tip of 6 Fr guiding catheter. D: Final angiographic result.
`
`PCI to the RCA was attempted and was unsuccessful but,
`owing to ongoing symptoms, the patient returned for a
`second procedure.
`
`PCI was performed from the right TRA using a 6 Fr JR4
`GC, with the left TRA used for contralateral injections.
`This provided inadequate guide support and thus it was
`exchanged for an Amplatz 1 (AL1) GC with additional
`back-up provided by the GuideLiner catheter (see Figure
`4). The occlusion was successfully crossed with a guide
`wire (Miracle 12, Asahi Intecc, Japan) and predilated with
`a 1.25 x 10 mm balloon and subsequently with a 2.0 x 33
`mm balloon. A 2.5 x 38 mm stent was easily passed to the
`distal vessel and two further stents used in the mid vessel
`with a good angiographic result (see Figure 4).
`
`Discussion
`In this report, we describe two cases of transradial
`intervention of chronic total occlusions assisted by the
`GuideLiner catheter. For RCA lesions, the optimal choice
`of catheter is one that can be deeply intubated in order to
`provide good backup support, but the use is limited, owing
`to the tendency towards causing dissections of the
`proximal vessel, especially when this segment of the RCA
`is severely diseased. To solve this problem, many
`
`techniques have been developed such as anchoring
`balloons6 the buddy wire technique9 and deep intubation
`using a Judkins Right GC.7 This device employs a straight
`tip inner GC which has a softer, more flexible straight tip
`and is of smaller caliber than a conventional GC. As such,
`it allowed us to deeply intubate the coronary artery. Good
`back-up support was provided with a low risk of coronary
`injury, enabling stent delivery in these complex cases.
`
`In our center, our approach for PCI is via the transradial
`route in >90 % of cases and recent data have shown our
`success rates for CTOs via this approach to be equivalent
`to transfemoral.14
`
`Previous studies have shown bilateral internal thoracic
`grafting to be more reliable than radial arterial grafting
`therefore we performed the procedure via a double radial
`approach in order to reduce vascular complications and
`also to allow earlier ambulation.15 In our experience, deep
`intubation of the GuideLiner catheter has provided
`improved back up in difficult lesions and led to successful
`opening of the CTOs and passage of the stents with safety.
`This novel coaxial system has wider application for
`complex lesions especially in the era of contemporary PCI
`where operators are approaching more difficult lesions. I
`
`1. Brueck M, Bandorski D, Kramer W, et al., A randomized comparison
`of transradial versus transfemoral approach for coronary angiography
`and angioplasty, JACC Cardiovasc Interv, 2009;2(11):1047–54.
`2. De Carlo M, Borelli G, Gistri R, et al., Effectiveness of the
`transradial approach to reduce bleedings in patients undergoing
`urgent coronary angioplasty with GPIIb/IIIa inhibitors for acute
`coronary syndromes, Catheter Cardiovasc Interv, 2009;74(3):408–15.
`3. Helft G, Dambrin G, Zaman A, et al., Percutaneous coronary
`intervention in anticoagulated patients via radial artery access,
`
`Catheter Cardiovasc Interv, 2009;73(1):44–7.
`4. Vorobcsuk A, Konyi A, Aradi D, et al., Transradial versus
`transfemoral percutaneous coronary intervention in acute
`myocardial infarction Systematic overview and meta-analysis, Am
`Heart J, 2009;158(5):814–21.
`5. Chase AJ, Fretz EB, Warburton WP, et al., Association of the arterial
`access site at angioplasty with transfusion and mortality: the
`M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion
`after percutaneous coronary intervention via the Arm or Leg),
`
`46
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`Angiographic Success and Successful Stent Delivery for Complex Lesions Using the GuideLiner™ Five-in-six System
`
`Summer 2011
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`
`Case Report
`
`Heart, 2008;94:1019–25.
`6. Dehghani P, Mohammad A, Bajaj R, et al., Mechanism and
`predictors of failed transradial approach for percutaneous
`coronary interventions, JACC Cardiovasc Interv, 2009;2(11):1057–64.
`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 anchor technique, Catheter Cardiovasc Interv,
`2003;59(4):482–8.
`8. Abhaichand RK, Lefevre T, Louvard Y, Morice MC, Amplatzing a 6 Fr
`Judkins right guiding catheter for increased success in complex right
`coronary artery anatomy, Catheter Cardiovasc Interv, 2001;53(3):405–9.
`Ikari Y, Nagaoka M, Kim JY, et al., The physics of guiding catheters
`for the left coronary artery in transfemoral and transradial
`interventions, J Invasive Cardiol, 2005;17(12):636–41.
`10. Rigattieri S, Hamon M, Grollier G, The buddy wire technique is
`useful in transradial coronary stenting of complex, calcified
`lesions: report of three cases, J Invasive Cardiol, 2005;17(7):376–7.
`
`9.
`
`11. Hayashida K, Louvard Y, Lefèvre T, Transradial complex coronary
`interventions using a five-in-six system, Catheter Cardiovasc Interv,
`2011;77(1):63 –8.
`12. Takahashi S, Saito S, Tanaka S, et al., New method to increase a
`backup support of a 6 French guiding coronary catheter,
`Catheter Cardiovasc Interv, 2004;63(4):452–6.
`13. Shaukat A, Al-Bustami M, Ong PJ, Chronic total occlusion--use of a
`5 French guiding catheter in a 6 French guiding catheter, J Invasive
`Cardiol, 2008;20(6):317–8.
`14. Moynagh, A, Benamer H, Louvard Y, et al., A comparison of the
`success rates of transradial and transfemoral approaches for
`percutaneous coronary intervention of chronic total occlusions,
`Presented at Transcatheter Therapeutics 2010, Washington, DC.
`September 21–25, 2010.
`15. Fukui T, Tabata M, Manabe S, et al., Graft selection and one-year
`patency rates in patients undergoing coronary artery bypass
`grafting, Ann Thorac Surg, 2010;89(6):1901–5.
`
`Summer 2011
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`Angiographic Success and Successful Stent Delivery for Complex Lesions Using the GuideLiner™ Five-in-six System
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