International Journal of Cardiology 222 (2016) 141–147
`
`Contents lists available at ScienceDirect
`
`International Journal of Cardiology
`
`journal homepage: www. else vi er. com/ locate/ijcard
`
`Review
`Guide extension, unmissable tool in the armamentarium of modern
`interventional cardiology. A comprehensive review
`Enrico Fabris MD a,c, Mark W. Kennedy MB, BCh, BAO a, Carlo Di Mario MD, PhD b, Gianfranco Sinagra MD c,
`Vincent Roolvink MD a, Jan Paul Ottervanger MD, PhD a,
`Arnoud W.J. van't Hof MD, PhD a, Elvin Kedhi MD, PhD a,Ì
`a ISALA Hartcentrum, Zwolle, The Netherlands
`b Royal Brompton Hospital & NHLI Imperial College, London, United Kingdom
`c Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
`
`a r t i c l e
`
`i n f o
`
`a b s t r a c t
`
`Due to the aging population undergoing percutaneous coronary intervention (PCI), interventional cardiologists
`are confronted daily with treatment of lesions with complex anatomy. Despite improvements in stent devices
`and PCI techniques, these lesions remain a challenge in terms of procedural success. Guide-extensions (GE) are
`coaxial “mother and child” catheters employed to facilitate device delivery but they can be used in many different
`complex scenarios. A comprehensive review of the possible applications of GE and of the GuideLiner™ (GL), the
`most widely used GE device, is missing. We therefore aim to provide a comprehensive review of all the potential
`applications of the GL and other GE devices, describe its limitations as well as tips and tricks for successful usage
`of this GE catheter.
`
`© 2016 Elsevier Ireland Ltd. All rights reserved.
`
`Article history:
`Received 15 June 2016
`Accepted 27 July 2016
`Available online 29 July 2016
`
`Keywords:
`Complex PCI
`Guide extension catheter
`GuideLiner
`
`1. Introduction
`
`With the increasing age of the population undergoing percutaneous
`coronary intervention (PCI) and advances in interventional cardiology,
`increasingly complex procedures are being faced on a regular basis. In
`coronary lesions with extreme tortuosity and/or calci cations, stent de-
`livery to the target lesion may be challenging despite adequate lesion
`preparation and improved deliverability of novel stent devices.
`Adequate back-up support remains the cornerstone for successful PCI.
`Extra back-up support guiding catheters and active support techniques,
`such as deep intubation in combination with either buddy wires and/or
`an anchor balloon, are commonly used to improve support. The “mother
`and child” concept of having a smaller catheter for intracoronary
`insertion through the conventional guiding catheter was introduced
`by skilful Japanese colleagues advising Terumo on the design of the
` rst dedicated device, the Heartrail™ system (Terumo, Japan). Unfortu-
`nately this system was cumbersome and required removal of the
`haemostatic valve followed by advancement over the coronary wire
`into and through the mother guide, with subsequent reconnection of
`the haemostatic valve to the proximal end of the Heartrail catheter.
`The GuideLiner™ (GL) catheter (Vascular Solutions, Minneapolis, MN),
`connecting a distal exible 20 cm catheter to steel rod, and allowing
`
`Ì Corresponding author at: Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The
`Netherlands.
`E-mail address: e.kedhi@isala.nl (E. Kedhi).
`
`http://dx.doi.org/10.1016/j.ijcard.2016.07.168
`0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
`
`for rapid exchange, being a monorail system, overcame most of these
`limitations and became the prototype of other similar guide-extension
`IMDS,
`the
`(GE) systems (Guidion™ Flexible Guide Extension,
`Netherlands and Guidezilla™ Guide Extension Catheter, Boston
`Scienti c, Boston). Since the rst-in-man report of the successful use
`of GL for distal stent delivery following failure of conventional
`techniques [1], this device has gained popularity and has been used
`for many other applications. The aim of this manuscript is to offer a
`complete overview of the current possible applications of the GL and
`other GE devices, to describe its limitations and to report results obtain-
`ed in prior studies.
`
`2. The GuideLiner and other guide extension devices
`
`The GL is a coaxial “mother and child” GE system, which has been
`developed for deep vessel engagement and device delivery; providing
`active guide support by its long exible tubular end, which can be deep-
`ly advanced into the target vessel. Unlike deep intubation of a guiding
`catheter, the GL has no primary curve and its soft distal tip promises a
`low dissection risk compared to deep seating of regular guides. The
` rst generation GL received FDA approval and CE marking in 2009 and
`was designed as a single lumen rapid exchange catheter with a exible
`20-cm tip connected by a metal collar to a 115-cm stainless steel shaft.
`The second-generation V2 system has a 5 cm longer exible tubular end
`and an all polymer collar for increased exibility; in the more recent V3
`the 25 cm rapid exchange section is maintained but with an additional
`
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`Fig. 1. Guide-extension catheters A) The GuideLiner™-V3 extension catheter. B) Guidion™ Flexible Guide Extension and C) Guidezilla™ Guide-Extension Catheter.
`
`“half-pipe” to assist device alignment when passing through the collar
`transition (Fig. 1) and to limit the incidence of stent collar interactions.
`The GL reduces the inner guide diameter by approximately 1Fr and is
`currently available in 4 sizes: 5.5, 6, 7, and 8 Fr. Once the guide catheter
`and guide wire are placed, the GL catheter can be advanced over the
`guide wire through the haemostatic valve as an extension to the guide
`catheter. Subsequently, the procedure can be continued as usual,
`without need for disconnection and reattachment. The Guidezilla™ is
`available only in a 6 Fr compatible version, with an inner lumen mini-
`mally larger than the corresponding GL (0.057″ instead of 0.056″),
`with a hypotube rather than a steel ribbon to improve pushability, a
`proprietary coating rather than silicone and with a polymer coated
`metal collar to facilitate device insertion at the transition point. The
`Guidion™ has a more exible atraumatic distal end; the most recent
`version promises to have better pushability and is available also in a
`5 Fr compatible version. Besides being usable with smaller 5 Fr guiding
`catheters, the 5 Fr option allows insertion alongside a balloon catheter
`(for instance during anchoring) and its use in combination with a 6 Fr
`guide extension to create a telescopic system able to reach more distal
`locations and offer greater support.
`
`3. Principal indication for device utilization
`
`Current published data shows that GL is primarily used in patients
`who are signi cantly older, more frequently have multi-vessel disease
`[2] and present lesions which are signi cantly more complex [2],
`more calci ed, and have longer lesion length [3] compared to patients
`
`in which PCI can be performed without using the device. The main GL
`case series/registries, which have described target lesions using the
`AHA/ACC lesion characteristics, report a percentage of B2/C ranging
`between 91 and 97% [3–5], and in the largest series [2] the percentage
`of Type-C lesions was 78% (Fig. 2). In the context of such complex
`anatomy, reported procedural success using the GL, in series with at
`least ten patients, ranges from 80% to 100% (Table 1).
`
`3.1. Presence of vessel angulation and tortuosity
`
`Despite improvements in second-generation stent design, including
`improved stent trackability, pushability and overall deliverability,
`severe vessel angulation and tortuosity remain the most frequent
`cause of procedural failure. The GL provides an elegant method to
`overcome this challenge, and represents one of the most common indi-
`cations for its use. Eddin et al. [2] have shown that proximal vessel an-
`gulation and lesion angle were the main predictors of GL use. A 45°
`proximal vessel angle predicted the need for GL use with a sensitivity
`of 73% and speci city of 74%. Chan et al. [6] have also reported that an
`angulated take-off of the target vessel and tortuosity represented the
`31% and 7%, respectively, of the indication for GL usage. Furthermore,
`coronary artery tortuosity, de ned as ≥3 bends of ≥45° or ≥1 bend of
`≥90° change in vessel direction, was identi ed in 43% of cases in a series
`of PCI with GL support [7]. Finally, proximal tortuosity was found in
`21.9% of cases by Dursun et al. [5] and severe tortuosity was reported
`in 35% of case in one of the largest series published [8].
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`143
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`Fig. 2. Percentage of AHA/ACC type lesions characteristics reported in published case series/registries. Left side: percentage of b2/C type lesions; right side: percentage of C type lesion.
`The width of the columns is representative of the sample size. Pts = patients.
`
`3.2. Presence of severe calci cation
`
`In vessels with heavy proximal calci cation, advancement of a stent
`to a distal target lesion can remain challenging, owing to signi cant
`friction between stent struts and the calci ed vessel wall. GL utilization
`in this particular situation has a dual bene t: it provides robust back-up
`and therefore improves stent trackability and when advanced until just
`proximal to the target lesion; it avoids friction between the stent and
`calci ed vessel wall. In the main case series, the presence of heavy
`calci cation in PCI performed using the device ranges from one-third
`to two-third of cases [1,5,7–9]. While use of rotational atherectomy
`may be necessary to provide full deployment of the stent in calci ed
`lesions [10], burr delivery to distal lesion sites can remain dif cult,
`particularly in tortuous anatomy, and in such situations is associated
`with an increased risk of vessel perforation. Anecdotal case reports
`have described the passage of the GL beyond the proximal tortuous
`segment facilitating burr delivery to distal calci ed lesions [11,12].
`
`1.25–1.5 mm burrs can be accommodated through a 7Fr GL [11,12].
`However the insertion of the burr through the collar can be challenging
`[11]. A way to overcome the problem is to manually load the burr inside
`the distal end of the GE outside the body advancing both together up to
`the ostium and then sliding the GE.
`
`3.3. Chronic total occlusion
`
`Chronic total occlusion (CTO) intervention represents one of the
`most challenging subsets of PCI. During CTO PCI, procedural failure is
`often due to an inability to deliver a balloon or micro-catheter across
`the lesion [13]. GL use achieves better support and deeper intubation
`of target vessels and its value has been demonstrated in numerous se-
`ries [6,13,14]. A single centre experience has reported use of GL in
`17.8% (66/372) of CTO procedures [13]. In 28 of these cases, GL assisted
`initial balloon or micro-catheter advancement to the culprit CTO lesion
`and in 6 of these cases was used to support the initial wiring of the
`
`Table 1
`Registries/case series including at least 10 patients.
`
`Studies
`
`Date of
`publication
`
`Number of
`pts
`
`Age
`(years)
`
`By pass
`n(%)
`
`Procedural
`success (%)
`
`Stent deformation or
`dislodgment (%)
`
`Coronary
`dissection (%) Other complications
`
`97%
`1(7.6%)
`67 ± 13
`90%
`–
`71 ± 10
`100%
`3(18.7%)
`68 ± 8
`90%
`2(9.5%)
`65 ± 13
`10(14.2%) 93%
`67 ± 13
`100%
`–
`69 ± 12
`–
`82%
`64 ± 10
`–
`87.5%
`72 ± 8
`12(21.8%) 98%
`69 ± 13
`3(4.6%)
`95%
`70 ± 10
`71.5 ± 11 28(8.5%)
`80%
`70.5 ± 10 2(1%)
`86%
`69 ± 10
`2(1.6%)
`93%
`
`2010
`Mamas et al. [1]
`13
`2011
`Cola et al. [9]
`10
`2012
`Dardas et al. [7]
`16
`2012
`Luna et al. [32]
`21
`2012
`De Man et al. [4]
`70
`2013
`Eddin et al. [3]
`22
`28a
`2013
`Kovavic et al. [13]
`15b
`Garcia-Blas et al. [34] 2014
`55c
`Chan et al. [6]
`2015
`Dursun et al. [5]
`2015
`64
`347d
`Waterbury et al. [2]
`2015
`188e
`Alkhall et al. [8]
`2016
`124f
`Alkhall et al. [8]
`2016
`a 1 patient had successful renal denervation.
`b 16 consecutive procedures in 15 patients.
`c All CTO procedures.
`d 363 procedures in 347 patients.
`e All procedures in which GuideLiner-V2 were used.
`f All procedures in which GuideLiner-V3 were used. n = number, Pts = patients.
`
`6.2%
`20%
`–
`–
`1.4%
`–
`–
`–
`–
`–
`2.3%
`11.1%
`2.4%
`
`–
`30%
`12.5%
`–
`–
`–
`–
`6.25%
`–
`–
`3.3%
`0.5%
`–
`
`–
`–
`–
`1 acute vessel closure; pressure damping in 57%
`1 air embolism
`–
`1 wire perforation
`–
`–
`–
`1 ventricular arrhythmia
`–
`–
`
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`lesion. The GL successfully facilitated micro-balloon crossing of the CTO
`lesion in 85.7% of cases (24/28), when a guidewire had already crossed
`the CTO. Similar procedure success (97%) was also reported from Chan
`et al. [6] in 33 CTO GL-facilitated PCI. Furthermore, during reverse
`controlled antegrade and retrograde subintimal tracking (CART) the
`advancement of the GL from the antegrade guide catheter can offer a
`visible and accessible target for the retrograde wire. “GuideLiner reverse
`CART” is an elegant modi cation of reverse CART shortening the dis-
`tance between the site of re-entry of the retrograde guidewire and the
`antegrade guiding catheter [15–17] (Fig. 3).
`
`3.4. Anomalous origin of coronary arteries or grafts
`
`Extreme take-off angulation, particularly in case of anomalous origin
`of coronary arteries represents a challenge to adequate catheter engage-
`ment, and may result in dissection or insuf cient support during PCI. GL
`utilization may improve both guide catheter coaxial orientation and
`support (Fig. 4). Ramanathan et al. [18] described an anomalous origin
`of a right coronary artery (RCA) arising from the left coronary cusp,
`where GL facilitated coaxial engagement and stent delivery after failure
`of conventional guides to achieve selective cannulation. Similarly, in a
`case with critical left circumex artery (LCX) stenosis, which arose
`from an anomalous LM coronary artery originating from the right
`sinus of Valsalva, GL was placed in the distal LM for additional support
`and avoided guide disengagement [19]. In a recent case, GL was success-
`fully used to enhance backup and increase pushing strength allowing
`stent deployment in distal LCX arising from a single left coronary artery
`[20].
`Similarly, one of the main dif culties in graft PCI, may be the near
`impossibility of coaxial engagement of the ostia. GE often provides the
`only solution to properly engage with adequate support both vein grafts
`in the ascending aorta or the mammary artery, especially in the
`presence of an extremely tortuous subclavian. Farooq et al. [21] have
`highlighted the feasibility of GE devices, including GL, to overcome
`many of these problems and facilitate trans-radial graft interventions
`in a series of selected complex cases. Park et al. [22] reported a
`challenging PCI in which GL allowed stent deployment in left anterior
`descending (LAD) artery through a tortuous left internal mammary
`artery (LIMA). Additional backup support for equipment delivery can
`be achieved by deep intubation of GL in the graft or indeed deep inser-
`tion of guide catheter over GL system (“Rail-Roading”). Finally, when
`
`Fig. 3. “GuideLiner reverse CART”. GuideLiner is advanced antegradely (arrows) to
`reduce the distance between the site of re-entry of the retrograde guidewire and the
`antegrade guiding catheter.
`
`faced with a proximal graft lesion, which may prevent deep guide intu-
`bation, further backup may be achieved with a ‘Swan-Neck’ maneuver
`[21] with the guide catheter positioned in the aortic sinus and tip of
`the GL extended to the vein graft ostium.
`
`4. Other possible applications
`
`Although GL was primarily designed to access discrete regions of the
`coronary vasculature, and to facilitate placement of interventional
`devices, other versatile applications of this device have been reported.
`
`4.1. Selective injection of target coronary segments to reduce contrast usage
`
`As the GL catheter is based upon a monorail rapid-exchange
`platform, contrast injections through the guiding catheter enter the
`proximal portion of the GL and exit it distally (selectively in the target
`segment). Since there is no loss of contrast into proximal side branches,
`the volume of contrast necessary for target vessel opaci cation is typi-
`cally lower than if injected through the guiding catheter alone [23].
`Serajian et al. [24] using the above-mentioned property, have shown
`that in situations with competitive LIMA ow, GL may be used for selec-
`tive LAD angiography. Using such a technique provided visualization of
`an LAD lesion, which otherwise was not well appreciated.
`Pershad et al. [25] after failed attempts to visualize a distal vessel
`because of the presence of proximal aneurysm with swirling of con-
`trast in the proximal segment, successfully used a GL catheter placed
`beyond the aneurysm to facilitate sub-selective injection into the
`distal vessel.
`
`4.2. Optical coherence tomography assessment of a vessel through the
`GuideLiner
`
`Optical coherence tomography (OCT) assessment through the GL
`may be another potential application. Mitomo et al. [26] reported a
`case in which a GL was used to facilitate OCT catheter delivery and min-
`imize the contrast dose used in a challenging complex lesion.
`
`4.3. GuideLiner for thrombectomy
`
`Stys et al. [27] and Farooq et al. [28] presented successful use of the
`GL for thrombus aspiration after failure of dedicated manual aspiration
`thrombectomy devices. The GL should be removed with the guide cath-
`eter fully intubated in the coronary ostium to prevent any potential em-
`bolization of thrombus to the systemic vasculature [28]. Further blood
`should be then aspirated from the guide catheter to ensure no thrombus
`remains within the guide catheter.
`An overview of potential indications for GE use is represented in
`Table 2.
`
`5. Potential complications
`
`As described, GL may signi cantly facilitate PCI; nonetheless it also
`carries some device-speci c complications; these include stent damage,
`stent loss, stent catheter deformation, dissection, air embolism and
`pressure dampening (see Tables 1 and 3). Awareness of the system lim-
`itations can simplify and render safer use of the device.
`
`5.1. Stent and balloon disruption
`
`The stainless steel collar present in the rst generation GL has been
`implicated in several instances of stent and balloon disruption [1,13,
`29]; and in fact the main limitation encountered at the beginning expe-
`rience of the device [1] was stent damage which occurred in two of the
`32 stents delivered (6.2%) as the stents were advanced through the
`catheter portion of the device. Similarly, Seto et al. [30] witnessed dam-
`age of stent struts in two cases upon attempted advancement through
`
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`Fig. 4. GuideLiner use for anomalous coronary origin. Anomalous origin of the right coronary artery from the left sinus (arrows). With only guiding catheters, it was very dif cult to
`visualize angiographically the vessel (A–B). The use of GuideLiner (*) is useful to properly engage the vessel and for a better diagnostic evaluation (C–D).
`
`Table 2
`Potential indications for guide-extension use.
`
`Potential indications
`
`the proximal GL collar, such resistance to stent advancement through
`the device, may be due to the lifting up (owering) of stent struts
`against the collar of the GL [31].
`
`Common indications
`Devices delivery in presence of vessel angulation and tortuosity [2,5–7]
`Devices delivery in presence of diffuse coronary calci cations [1,3–5,7–9]
`Facilitation of catheter engagement and intervention in anomalous coronary
`arteries [18–20] and grafts [21,22]
`Supporting the initial wiring or to assist advancement of balloon or micro-catheter
`during chronic total occlusion interventions as well as to facilitate re-entry of the
`retrograde guidewire.
`
`Other possible indications
`Selective injection of target coronary segments to reduce contrast usage [23]
`Focused injection to selective opaci cation of distal vessels in presence of proximal
`aneurisms [25] or presence of graft competitive ow [24]
`Thrombectomy in bail-out situations dealing with very large thrombus burden [27,28]
`Optical coherence tomography assessment of a tortuous vessel through the
`GuideLiner [26]
`Delivery of the burr and enabling safe rotational atherectomy in tortuous calci c
`lesion [11,12]
`
`Anecdotal cases
`Retrieval of entrapped rotablator burr using counter-traction with a GuideLiner [35]
`Maintenance of coronary guidewire position during exchange of the guide catheter [36]
`Renal denervation with the aid of a GuideLiner catheter [6]
`
`Table 3
`Lists of possible complications associate with GuideLiner use.
`
`Complications
`
`Notes
`
`Stent deformation on
`advancement or withdraw
`[1,2,4,8,30,31]
`
`Disruption of the stent catheter
`[8,29]
`
`Coronary Dissection [2,6,8,32]
`
`Pressure dampening [32]
`Air embolism [4]
`
`Dislodgement of the distal marker
`[31]
`
`It is more likely to occur when using guide
`catheters with a secondary bend
`Newer GL-V3 should prevent deformation
`and/or damage on advancement
`The proximal collar cut the stent delivery balloon
`shaft while GL was withdrawn backwards to
`‘unsheathe’ a delivered stent. Occurred using a
`sharply angled Kimny guide catheter.
`Also observed with a 6-Fr GL catheter in 7-Fr
`Kimny guiding catheter during forceful dye
`injection with GL catheter ejection forward
`creating the dissection.
`Mainly observed during “6-in-7” Fr GL
`As a result of insuf cient venting of the
`wedged GL
`Occurred after extensive manipulations.
`Dislodgement of the distal marker was
`possibly due to damage of the GL inner lining
`from a deformed stent.
`
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`Stent deformation or dislodgement may also occur on attempted
`withdrawal of a stent through the distal band of the GL. Moreover
`when combined with a sharply angled guide catheter, upon retraction
`of the GL, the proximal collar may kink and disrupt the stent shaft cre-
`ating a leak which prevents transmission of deployment pressure to
`the balloon [29].
`In a recent registry of 363 consecutive PCI procedures stent
`disruption and loss occurred in 8/363 (2.2%) of cases [2]. The incidence
`of this complication has decreased over time, with cases involving the
` rst generation GL device (V1) (n = 144) accounting for six out of
`eight cases of stent loss, two cases occurring with the second generation
`device (V2) (n = 119) and none with the third generation (V3) (n =
`100) [2]. However, a recent experience [8] has suggested that the
`V2-GL had a higher incidence of complications (10%, n = 19/188, of
`stent/proximal collar interaction), especially when using the right radial
`approach, compared with V1-GL historical data [1,4,32]. The possible
`mechanistic explanation for the reported increase in complications
`with V2, may reside in its length (25 cm) which frequently placed the
`proximal collar within the brachiocephalic and right subclavian seg-
`ments; an area which may be subject to ovoid distortion with respira-
`tion and therefore a potential space between the guide catheter and
`the GL may be created, allowing interaction with the stent [8]. The
`same authors demonstrated that the latest modi cations with the GL
`version 3 (V3) seem to have ameliorated these complications when
`compared with older generation [8]: with zero cases of proximal
`collar-stent interaction, only one case (0.8%, n = 1/124) of longitudinal
`stent deformation and two incidents (1.6%, n = 2/124) of stent
`interaction with the distal edge of the V3 GL described.
`
`5.2. Pressure dampening
`
`In one case series [32], using primarily 7F GL catheters, pressure
`dampening was frequently observed in 57% (12/21) patients, with one
`patient developing acute vessel closure, likely due to dissection [32].
`Pressure dampening occurring with GL use may directly contribute to
`unsuccessful of GL use.
`
`5.3. Coronary dissections
`
`Despite the GL being equipped with a softer tip than standard cath-
`eters, dissection of the coronary vessels may occur, particularly during
`deep intubations. The incidence of this event observed in a large registry
`[2] was 3.3%. Chang et al. [15] reported a LM dissection which occurred
`with a 6-Fr GL in 7-Fr Kimny guiding catheter during forceful dye
`injection: with forceful injection, the GL was ejected forward, resulting
`in a type D LM dissection. Therefore, removing GL from the loaded
`
`guiding catheter after completion of PCI for a nal control angiogram
`is recommended.
`
`6. Practical tip and tricks
`
`• On initial insertion of the GL the at push-rod should be oriented in a
`lateral position within the guiding catheter and should be advanced
`within the guiding catheter without rotation to avoid wrapping the
`guidewire around it [33].
`• In situations where the GL itself cannot be easily advanced due to the
`primary vessel anatomy, this can be facilitated by inating a balloon in
`the target lesion and use it as an anchor improving in this way the
`support of the guide catheter while advancing the GL through com-
`plex anatomy [2] (Fig. 5).
`• In the case of resistance while inserting a wire or stent through the GL:
`1) ensure the combination of the wire and stent is compatible with
`the internal diameter of the GL; 2) If a secondary wire is in use,
`check for wire wrapping of the secondary wire around the GL; if
`wire wrap is evident, consider pulling back the secondary wire and
`re-advancing it; 3) check the location of stent in relationship to the
`collar of the GL. If resistance occurred in that segment the stent should
`be inspected for signs of damage prior to re-advancement [33].
`
`Advancement of coronary stents across the rapid exchange
`transition zone can be eased by positioning the transition zone of the
`GL in a straight portion of the guiding catheter in order to facilitate
`the passage of devices through it [6]. Ideally when using a radial
`approach, the connection to the exible segment should be situated in
`the ascending aorta [8].
`
`• Interventions requiring nal kissing balloon ination are feasible with
`the use of 6-in-7 (and, where necessary, 7-in-8) GL [6]. If coronary
`guidewires have been placed in the main vessel and side branch, GL
`must to be inserted over both coronary guidewires [6]. Inserting a
`new guidewire can be dif cult and if a guidewire is needed while
`the GL is already in situ, meticulous attention has to be paid to ensure
`the guidewire passes through the lumen of the GL tubing rather than
`outside by direct visualization on uoroscopy.
`• Every effort should be undertaken to minimize pressure dampening,
`however some degree of pressure dampening seems almost inevita-
`ble. Meticulous attention must be paid to ensure that adequate
`antegrade coronary ow is preserved and that no injury has occurred
`before proceeding with the intervention [32]. Stenting of long lesions
`with multiple stents is preferably done from distally to proximally,
`however when the proximal segment of the vessel is also severely ste-
`nosed, treatment of this segment initially can facilitate the engage-
`ment of the GL catheter proximal to the distal lesion [1].
`
`Fig. 5. GuideLiner anchoring balloon technique. Insertion of the guidewire (A), then the GuideLiner is passed up to the distal end of the guiding catheter (arrow) followed by a balloon
`that is inated in the distal lesion (B). The GuideLiner is then advanced into the vessel over the inated balloon reaching the position (arrow) that allows stent delivery (*)(C).
`
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`E. Fabris et al. / International Journal of Cardiology 222 (2016) 141–147
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`147
`
`• After removal of GL/GE is important to allow back bleeding to prevent
`air embolism during subsequent contrast injection
`
`7. Conclusion
`
`The GL “mother in child” extension catheter has signi cantly im-
`proved procedural outcomes in complex lesion anatomy and broadened
`the subset of lesions where PCI can be successfully performed. Compli-
`cations with GL application are possible and operators should be aware
`of them, however the latest improvements in catheter design have
`signi cantly reduced the risk of potential device related complications.
`GL can be nowadays considered a vital tool in the armamentarium of
`the modern interventional cardiologist.
`
`Conict of interest
`
`The authors have no conict of interest to declare.
`
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