` GUIDELINER® CATHETER
`
`
`
`
`
`GuideLiner Catheter Used for
`Proximal to Distal Stent Technique
`
`PHYSICIAN
`
`Steven S. Roh, MD, FACC
`North Memorial Heart and Vascular Institute
`
`Robbinsdale, Minnesota
`
`PRESENTATION
`
`A patient was admitted to the hospital with refractory Canadian
`Class IV angina. He had undergone a previous five vessel CABG in
`1997 and was studied by angiography six months earlier. On his
`previous study, he had native three vessel coronary artery disease.
`His LIMA to LAD, SVG to diagonal, and SVG to PDA were patent. His
`posterior and lateral walls were vulnerable to ischemia due to his
`occluded sequential SVG to the OM and posterolateral branches.
`He was treated with medical management but continued to have
`life limiting angina despite his maximum antianginal therapy. His
`angina continued to crescendo until his day of admission.
`In the
`week prior to his admission, he had taken up to twenty sublingual
`nitroglycerin tablets.
`
`INITIAL FINDINGS
`
`Coronary and graft angiography performed during the most
`recent admission was without changefrom the previous study.
`The patient had clearly failed medical therapy. The source of
`his ischemia was the posterolateral wall due to limited native
`flow from the RCA andlimited retrogradefilling from the SVG to
`the PDA. Angiography suggested that he would benefit from
`revascularization of the posterolateral branch of the RCA.
`
`TREATMENT
`
`The diagnostic angiogram of the RCA demonstrated a technically
`challenging PCI due to the numerous acute bends within the
`RCA,including the greater than 90° angle from the distal RCA to
`the posterolateral branch, and the severe diffuse disease within
`the entire RCA (Figure 1). Even the initial guide selection was a
`challenge due to the significant lesion in the ostial and proximal
`RCA. Asa result, a 6F JR4 guide was chosen to cannulate the RCA
`to allow for the necessary guide manipulations. A 300cm CholCE®
`PT guidewire was advancedinto the distal PLA. The lesion in the
`distal RCA/proximal PLA was predilated (with great difficulty) with
`a 1.5 x 20mm OTWballoon (Figure 2). The first challenge in the
`case came from the deep seating of the guide catheter to provide
`the support for advancing the OTW balloon catheter across the
`chronically occluded distal RCA/proximal PLA branch.
`
`With the necessary deep seating of the guide there was ulceration
`of the proximal RCA and acute vessel occlusion (Figure 3). To
`resolve this, the proximal RCA wasstented.
`
`(continued on back)
`
`Page 1
`
`VSIQXM_E00044660
`
`Teleflex Ex. 2188
`Medtronicv. Teleflex
`
`
`Page 1
`
`Teleflex Ex. 2188
`Medtronic v. Teleflex
`
`

`

`
`
`The fact that there were freshly laid stent struts in the proximal
`RCAofthis tortuous vessel would have prevented delivery of the
`distal stents, especially within a 6 French system. Therefore, the
`GuideLiner was advancedpast the freshly laid stent struts into
`the distal RCA. Then, using the GuideLiner and the guidewire as
`a“rail’, the JR4 guide catheter was advanced into the mid RCA to
`provide greater backup for delivery of the distal coronary stent past
`the numerous acute angles. The GuideLiner wasthe pivotal tool
`neededto achieve the necessary backup and delivery of the distal
`stents into proximal and mid PLA. Following these manipulations
`and maneuvers,a 2.5 x 28mm PROMUS?®drug-eluting stent
`was easily delivered to the proximal to mid PLA (Figure 4). A
`subsequent DES was delivered proximally through the GuideLiner.
`Once the stent was positioned, the GuideLiner was pulled back to
`“unsheath’the stent at the site of the lesion
`
`(Figure 5). GuideLiner was the pivotal tool to achieve the
`successful percutaneous revascularization of this technically
`difficult vessel (Figure 6).
`
`CONCLUSION AND POST PROCEDURE
`
`Upon the three month follow up visit, the patient’s angina
`significantly improved so muchso that the patient has resumed
`exercising on his treadmill and has just built a garage for his home.
`The GuideLiner catheter provided the necessary support to stay
`within a 6F guide system and successfully revascularize a highly
`tortuous, chronically occluded, distal RCA.First, the GuideLiner
`catheter provided the necessary “rail” to successfully deep seat a
`guide catheter into the mid segment of the highly tortuous RCA.
`The GuideLiner catheter then provided the support necessary to
`deliver a "long" stent across a greater than 90° bend,in the distal
`segmentof a tortuous vessel. In summary, the GuideLineris a novel
`tool to support stent delivery, which may be usedto facilitate
`proximal to distal deployment or to "unsheath”a stent within a
`coronary lesion rather than pushing the exposed stent across the
`lesion.
`
`
`
`
`
`
`
` TREATMENT(CONTINUED)
`
`Steven S. Roh, MD, FACC
`Steven S. Roh, MD, FACC has his ABIM Certification in
`Interventional Cardiology and Cardiovascular Diseases
`as well as his CBNC Certification in Nuclear Cardiology.
`He attended medical school at Indiana University School
`of Medicine and his residency was at the University of
`Minnesota Hospital and Clinics. He studied Cardiology
`at Oregon Health Sciences University and Interventional
`Cardiology at the University of Wisconsin. His specialties
`are Interventional Cardiology, Nuclear Cardiology
`and General Cardiology. His current location is North
`Memorial Heart and Vascular Institute in Robbinsdale,
`Minnesota.
`
`
`
`GuideLiner catheters are intended to be used in conjunction with guide catheters to access discrete regions of the coronary
`and/or peripheral vasculature, and to facilitate placement and exchangeof guidewires and other interventional devices.
`Please see theInstructions for Use fora completelisting of the indications, contraindications, warnings and precautions.
`CAUTION:Federal law (U.S.A.) restricts this device to sale by or on the orderof a physician.
`GuideLineris a registered trademark of Vascular Solutions,Inc.
`All other trademarks and registered trademarks are property of their respective owners.
`©2016 Vascular Solutions,Inc.All rights reserved. ML2369 Rev. B 10/16
`
` SOLUTIONS
`
`Vascular Solutions,Inc.
`6464 Sycamore Court North
`Minneapolis, Minnesota 55369 USA
`CustomerService:
`United States: 888.240.6001
`International: (001) 763.656.4298
`customerservice@vasc.com
`www.vasc.com
`
`Page 2
`
`VSIQXM_E00044661
`
`Teleflex Ex. 2188
`
`Medtronic v. Teleflex
`
`
`Page 2
`
`Teleflex Ex. 2188
`Medtronic v. Teleflex
`
`