Summary
Coronary stent delivery can be extremely challenging in tortuous and calcified lesions especially when radial approach is chosen. Guide extension catheter is a useful tool for overcoming the inherent difficulties arising by the use of radial access in complex percutaneous interventions. We describe a technique for guide extension catheter system advancement by presenting two cases. This was performed stepwise by repeated distal balloon anchoring in the coronary artery of interest.
Highlights
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Guide extension catheters are useful tools in complex percutaneous interventions through radial access.
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Advancing the guide extension catheter through tortuous and calcified lesions is challenging.
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Repeated distal balloon anchoring facilitates the use of guide extension catheters.
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Background
Radial access has gained increasing popularity among interventional cardiologists, because it is associated with consistently lower rates of bleeding and vascular complications compared to femoral access, without a compromise in procedural success rates . However, percutaneous treatment of complex coronary lesions remains a challenge, especially in the era of radial approach. Taking in mind the significantly lower support offered by radial approach compared to femoral, the frequent limitations regarding the use of higher caliber catheters, the presence of vessel calcification and marked tortuosity lead often to failure of stent advancement and properly deployment. Many techniques have been developed in order to overcome the lack of guide catheter support, such as the use of extra support catheters with a back-up against the opposite aortic wall, stiffer wires, deep intubation of the guide catheter, anchoring and using of a second buddy wire . Guide extension catheter (GEC) is a new tool that can be extremely useful in the clinical setting of percutaneous treatment of complex coronary lesions, that have mostly been used to facilitate equipment delivery or provide vessel support and engagement . However, the advancement of the GEC further in a coronary under the aforementioned conditions (tortuosity, calcification) can be rather challenging. The insufficient advancement of the GEC is associated with unsuccessful balloon or stent delivery . We describe a technique to facilitate guide extension catheter stepwise advancement through repeated distal balloon anchoring, by presenting two cases from two different medical centers.
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Description of clinical cases
- Case 1:
A 64 year old man was admitted to Red Cross Hospital (Greece) with the diagnosis of unstable angina. He was a current smoker, had hyperlipidemia under treatment and had a history of prior PCI of proximal left anterior descending artery (LAD), due to stable angina 5 years ago. He was treated with ticagrelor loading dose (on top of the aspirin he was already using) and enoxaparin subcutaneously. The echocardiogram performed showed normal left ventricular function and no valve dysfunctions. A coronary catheterization was performed without any non-invasive evaluation from the right radial artery, revealing a left main (LM) without lesions, atherosclerotic LAD and left circumflex (LCX) arteries without significant stenosis. The previous stent in LAD was patent. Right coronary artery (RCA) was very tortuous at the proximal part (shepherd’s crook morphology) and had a long, calcified, 80% stenosis at its middle part ( Fig. 1 ). A strategy of ad hoc PCI for the right coronary artery was decided. A 7F Amplatz Left 1 (AL1) guide for a better back-up was chosen, because of the lesion complexity. The guiding catheter was placed at the right coronary artery ostium and a Luge guidewire (Boston Scientific) was inserted until the distal part of RCA. Lesion pre-dilatation was performed with a 2.5 × 15 mm Sprinter balloon (Medtronic). However, the Resolute Integrity stent (Everolimus Eluting stent 2.75 mm × 24 mm) would not reach the lesion due to the extreme proximal tortuosity and calcification. A Guidezilla guide extension catheter (Boston Scientific) was used, but it could not be advanced more than a few millimeters from the ostium of the RCA. As a next step a new 2.5 × 15 mm Sprinter balloon was inserted and a few millimeters distally from the Guidezilla tip and inflated at 8 atm, in order to be used as an anchor. The Guidezilla was successfully advanced until the proximal tip of the inflated balloon (Video 1). Then the balloon was deflated, advanced distally and inflated again at 8 atm. The Guidezilla catheter was advanced once more up to the proximal part of the anchoring balloon (Video 2), until it was distally to the main part of the stenotic lesion. After that the previously selected stent was advanced in the GEC and when it was covering the distal part of the lesion, the extension catheter was withdrawn and the stent was deployed. Two more stents were deployed by the same way in the proximal diseased segment (partly also due to the extensive manipulations) in order to cover the full lesion length with excellent final angiographic result ( Fig. 2 ).
Fig. 1
Fig. 2
- Case 2:
An 88 year old woman was admitted to Leiden University Medical Center (Netherlands) because of a non-ST elevation myocardial infarction. Her previous medical history included hypertension, panhypopituitarism and a multivessel percutaneous coronary intervention with bare metal stents of LM, LAD, LCX and RCA nine months ago. PCI was chosen at that time over CABG because of her age and extensive co-morbidity. Echocardiography revealed mild impairment of left ventricle function (estimated ejection fraction 50%) with basal inferior and basal and mid-lateral hypokinesia. A coronary angiogram was performed within 24 h from admission, using the radial access. A 6F radial sheath was inserted. The coronary angiography revealed distal LM 80–90% in-stent restenosis, 90% LAD in-stent restenosis and a proximal 90% LCX in-stent restenosis ( Fig. 3 ). A JL4 guiding catheter was used. A BMW and a Pilot 50 wires were placed at the distal LAD and distal LCX respectively. LAD pre-dilatation with a 2.0 mm and a 3.0 mm non-compliant balloons and LAD stenting with 2 DES (Resolute Onyx 3.0 mm × 18 mm and 3.0 mm × 25 mm) were performed without significant difficulties (up to the ostium of the LAD). Stenting the LM/LCX lesion on the other hand proved far more challenging because of the vessel calcification and severe proximal angulation. Despite the pre-dilatation of the LM and LCX with 2.0 mm and 3.0 mm non-compliant balloons, the delivery of a stent (Resolute Onyx 3.5 mm × 26 mm) from LM to LCX was unsuccessful. An initial attempt to improve the guiding catheter support through the use of a Guidezilla failed, since the GEC was also unable to overcome the proximal angulation and be placed deep enough in the coronary. Therefore, a 2.0 mm × 20 mm semi-compliant balloon was placed and inflated at 10 atm just after the distal tip of GEC (Video 3) and was used as an anchor for the advancement of GEC. The repeated inflation of the balloon and the gradual forwarding contributed to overcome the angulation and successfully place the GEC up to the proximal CX. A 3.5 mm × 26 mm and a 3.5 mm × 12 mm DES Resolute Onyx were delivered through the GEC to mid LCX and proximal LCX–LM respectively and deployed after guide extension catheter withdrawn, with favorable angiographic result. A final dilatation with a 3.0 mm balloon was performed toward the LAD to open the struts and optimize blood flow ( Fig. 4 ).
Fig. 3
Fig. 4 
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