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`Technical report
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`The GuideLiner™ “child” catheter
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`Usha Rao1, MBBS, MRCP; Diana Gorog1,2, MRCP, MD, PhD; Jacek Syzgula1, MD, PhD; Sanjay Kumar,
`BSc, MBBS, MRCP; Carley Stone3; Neville Kukreja1, MA, MBBS, MRCP
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`1. Department of Cardiology, East and North Hertfordshire NHS Trust, United Kingdom; 2. Imperial College, London, United
`Kingdom; 3. Pyramed Ltd, Ashby De La Zouch, Leicestershire, United Kingdom
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`Carley Stone is an employee of Pyramed Ltd. The other authors have no conflict of interest to declare.
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`Introduction
`Despite the advancement in percutaneous interventional
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`delivered through standard guide catheters, resulting in an inner
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`diameter that is approximately one French size smaller than the
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`procedures including newer stents and better delivery systems, the
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`guide. The GuideLiner™ is currently available in three sizes: 5-in-6
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`failure to deliver a stent to the target lesion, especially in arteries
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`(0.056” internal diameter), 6-in-7 (0.062” internal diameter) and 7-
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`with complex anatomy, remains a common problem. Various
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`in-8 (0.071” internal diameter).
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`techniques have been used to solve or rather help with this
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`The extension is 20 cm long, but a maximum extension of only 10 cm
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`dilemma including straightening the artery with a second “buddy”
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`is recommended and has a silicon coating for lubricity. The extension
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`wire1 or “buddy” balloon, larger and more supportive guiding
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`section is a component built tube composed of an inner
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`catheters, or deep intubation with the guiding catheter for back up
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`polytetrafluoroethylene (PTFE: Teflon) liner, a middle stainless steel coil
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`support. The Heartrail II (Terumo, Tokyo, Japan) “five in six
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`(which provides maximum flexibility while retaining radial strength)
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`catheter system” also called ”mother and child”, involving the
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`and an outer polyether block amide (Pebax) polymer extrusion (same
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`insertion of a flexible tipped extra length (120 cm) 5 Fr catheter for
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`material as a guide catheter, and does not soften at body temperature).
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`deeper intubation with extra back-up support, has been described
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`There is a radio-opaque marker located 0.105” (2.66 mm) from the tip
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`in the literature, and is an accepted technique for improving
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`(Figure 1). The guide extension is connected to the push tube with a
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`support and delivering stents in difficult cases2-5. More recently, a
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`“collar”: guidewires, balloons and stents enter the collar within the guide
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`new “child” support catheter has been introduced: the
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`catheter (Figures 1 and 2). The delivery through the guide is designed to
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`GuideLiner™ (Vascular Solutions, Minneapolis, MN, USA). The
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`be tight in order to prevent slippage within the guide catheter. There are
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`device received CE marking in September 2009.
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`white positioning markers on the push tube at 95 cm (single) and 105
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`cm (double) to assist in placement through the guide (Figure 1).
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`Device and technical details
`The GuideLiner™ catheter is a coaxial guide extension with the
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`convenience of rapid exchange. In difficult and challenging
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`Indications for use
`1. Deep seating for added back-up guide support in challenging
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`interventions guide catheters have a tendency to back out of the
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`coronary cases to facilitate device delivery.
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`artery whereas the GuideLiner™ allows guide extension into the
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`2. Coaxial alignment when irregular coronary ostium take-off
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`vessel for deep seating. This simplified mother and child technique
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`prevents guide placement.
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`is useful in challenging interventions and for rapid exchange.
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`Use of the GuideLiner™ catheter is contraindicated in vessels with
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`It is composed of a flexible 20 cm straight guide extension for deep
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`less than a 2.5 mm diameter.
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`seating, connected to a stainless steel push tube with a “collar”
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`which can be deployed through the existing Y-adapter for rapid
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`exchange delivery (Figure 1). Unlike the Heartrail catheter, the
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`Tips and tricks for optimal performance
`1. The GuideLiner™ should be inserted into the guide catheter over
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`GuideLiner™ does not increase the overall guiding catheter length
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`a 0.014” primary guidewire to a maximum of 10 cm beyond the
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`or require a second haemostatic valve, and due to its monorail
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`guide tip under fluoroscopy and in no case more than 20 cm to
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`design is simpler to use than the Heartrail. The GuideLiner™ can be
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`prevent the metal collar from exiting the guiding catheter.
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`* Corresponding author: East and North Hertfordshire NHS Trust, Cardiac Suite L94, Lister Hospital, Stevenage SG1 4AB, Hertfordshire, United
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`Kingdom
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`E-mail: neville.kukreja@btinternet.com
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`© Europa Edition 2010. All rights reserved.
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`EuroIntervention 2010;6:277-279 published online ahead of print May 2010
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`The GuideLiner™ “child” catheter
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`Figure 1. The GuideLiner™ catheter. This consists of a flexible 20 cm straight guide extension connected to a stainless steel push tube.
`* radiopaque marker 2.66 mm from tip. Arrows: white positioning markers at 94 cm (single arrow) and 105 cm (double arrows).
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`2. On initial insertion of the GuideLiner™, the flat push-rod should
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`be oriented in a lateral position within the guiding catheter and
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`should be advanced within the guiding catheter without rotation
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`to avoid wrapping the guidewire around it.
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`3. Deep seating of the GuideLiner™ in the coronary artery can be
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`facilitated by using an un-inflated balloon catheter over the
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`primary wire into distal vessel – if necessary this can then be
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`inflated at the target lesion to act as an anchor, followed by gentle
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`advancement of the GuideLiner™.
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`4. Stents should be advanced over the primary guidewire through
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`the GuideLiner™ as secondary wires may wrap around the
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`GuideLiner™ push tube, obstructing stent insertion.
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`5. In case of resistance while inserting a guidewire or stent through
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`the GuideLiner™, the location of the wire or stent in relationship
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`to the metal collar of the GuideLiner™ should be checked and
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`the stent inspected for signs of damage prior to re-advancement.
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`To correct any resistance that occurs at (or proximal to) the collar:
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`a. Ensure the combination of the wire and stent is compatible
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`with the internal diameter of the GuideLiner™.
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`b. If a secondary wire is in use, check for wire wrapping of the
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`secondary wire around the GuideLiner™. If so, consider either
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`pulling back the secondary wire or re-advancing it, or if the
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`primary wire (placed before GuideLiner™ insertion) is still in
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`place consider advancing the stent over the primary wire.
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`c. If a stent continues to encounter resistance at the metal collar,
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`pull the stent and guidewire back together 3-5 cm and try re-
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`advancing the stent and guidewire together through the metal
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`collar. If resistance is again encountered, check the stent for
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`signs of damage and either choose a lower profile stent or
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`change the guidewire.
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`Clinical experience
`A 74 year-old patient with previous coronary artery bypass grafting in
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`2003 was admitted with a non–ST elevation myocardial infarction
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`(NSTEMI) and inferolateral ST segment changes. His angiogram
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`showed a moderate lesion in the proximal left anterior descending artery
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`Figure 2. Insertion of the GuideLiner™. The monorail GuideLiner
`catheter is inserted into a guiding catheter over a guidewire (GW) (i).
`Once advanced into the guiding catheter, the GuideLiner push tube
`can be advanced whilst holding the GW in place (ii). The GuideLiner
`can be advanced up to 10 cm beyond the guiding catheter tip (iii).
`Balloons or stents (S) can be advanced along the guidewire (iv),
`through the GuideLiner to the target lesion (v).
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`Technical report
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`(LAD) and a tight stenosis in the circumflex ostium. The graft to the LAD
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`The GuideLiner™ provides a new alternative for performing
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`was occluded but there was a patent jump graft to an obtuse marginal
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`complex interventions. Benefits include:
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`and posterior descending artery. The right coronary artery (RCA) was
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`1. Deep seating with a straight, highly flexible guide extension.
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`tortuous and calcified with tight stenoses in the proximal and mid vessel
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`– Unlike deep intubation of a guiding catheter, there is no primary
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`(Figures 3a and 3b). Percutaneous intervention to the native RCA was
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`curve to potentially damage and dissect the vessel.
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`performed transfemorally using a 6 Fr sheath inserted in the right
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`– Coil backbone provides superior flexibility while retaining radial
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`femoral artery. Initially a Hockey stick guiding catheter was used which
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`strength.
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`was changed to an Amplatz Left (AL) 1 guide for better engagement. The
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`2. The device only reduces the lumen by approximately one French
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`RCA was then wired using a BMW wire (Abbott Vascular, Redwood City,
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`size, so almost all devices will still fit through a 6 Fr GuideLiner™
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`CA, USA ) and pre-dilated with a 2.5 x 15 Maverick balloon (Boston
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`(internal diameter 0.056”).
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`Scientific, Natick, MA, USA) (Figures 3c and 3d). However, due to a
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`3. Rapid exchange aids deployment through the existing
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`combination of calcification and tortuosity, a stent could not be delivered.
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`After further dilation with a 3.0 x 15 mm Maverick balloon, it was still
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`impossible to advance a stent. Therefore, a GuideLiner™ catheter was
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`haemostatic valve without extending the guiding catheter length,
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`and so does not limit the usable length of balloons and wires.
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`deployed through the AL1 guide and advanced into the mid RCA to aid
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`References
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`stent delivery (Figure 3e). This enabled the easy deployment of four
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`overlapping drug-eluting stents from the mid-vessel to the ostium
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`(3.5 x 15 mm, 3.5 x 18 mm, 3.5 x 23 mm and 3.5 x 8 mm; all Promus;
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`Boston Scientific, Natick, MA, USA). The overlaps were post-dilated with
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`a 3.5 x 8 mm non-compliant balloon (Quantum Maverick; Boston
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`Scientific, Natick, MA, USA) whilst the ostium of RCA was post-dilated
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`1. Jafary FH. When one won’t do it, use two-double “buddy” wiring to
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`facilitate stent advancement across a highly calcified artery. Catheter
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`Cardiovasc Interv 2006;67:721-3.
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`2. Takahashi S, Saito S, Tanaka S, Miyashita Y, Shiono T, Arai F,
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`Domae H, Satake S, Itoh T. New method to increase a backup support of
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`a 6 French guiding coronary catheter. Catheter Cardiovasc Interv
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`and flared with a 4 x 8 mm non-compliant balloon (Quantum Maverick;
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`2004;63:452-6.
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`Boston Scientific, Natick, MA, USA). A good angiographic result was
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`achieved (Figure 3f). The patient was discharged the following day with
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`no complications.
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`Discussion
`In this case, stent delivery was impossible despite the use of a
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`highly supportive guiding catheter. By using the GuideLiner™, the
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`stent was deployed easily and successfully because of the extra-
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`back up support and deep intubation without any displacement of
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`3. Shaukat A, Al-Bustami M, Ong PJ. Chronic total occlusion—use of
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`a 5 French guiding catheter in a 6 French guiding catheter. J Invasive
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`Cardiol 2008;20:317-8.
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`4. Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the
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`Heartrail III catheter as a stent delivery catheter following failure of con-
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`ventional techniques. Catheter Cardiovasc Interv 2008;71:358-63.
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`5. Mamas MA, Eichhöfer J, Hendry C, El-Omar M, Clarke B, Neyses L,
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`Fath-Ordoubadi F, Fraser D. Use of the Heartrail II catheter as a distal
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`stent delivery device; an extended case series. EuroIntervention
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`the guide catheter or the wire or any vessel trauma.
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`2009;5:265-71.
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`Figure 3. Clinical use of the GuideLiner™. (a) and (b) Diagnostic angiogram of the right coronary artery. (c) Using an Amplatz Left 1 guide, the
`lesions were crossed with a BMW wire. (d) The lesions were pre-dilated but a stent could not be advanced. (e) The GuideLiner™ (arrow) was
`advanced up to the lesion to allow deployment of the stent (arrowhead). (f) Final angiographic result.
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