Abstract
Popularity of microcatheters (MCs) is growing among interventional cardiologists, especially when complex coronary anatomy is involved. However, MCs are still considered by many as a niche tool and their value in common clinical practice and in the setting of acute coronary interventions has not been fully appreciated. This case report highlights the decisive role of MC use in the successful completion of a primary percutaneous coronary intervention. Characteristics and indications of the most commonly used MC are briefly discussed.
Highlights
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Microcatheters represent a valuable tool in treating challenging coronary anatomy.
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They are not solely purposed for chronic total occlusion cases.
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They are indispensable in any modern cathlab. Learn how to use them.
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Also for microcatheters it holds that one size does not fit all! Choose wisely.
1
Introduction
Microcatheters (MCs) are a useful tool in complex lesions and chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). They significantly increase success rates by enhancing the penetrating power of guide wires and facilitating guide wire exchanges . However, their value in the acute coronary syndrome setting has never been assessed. In daily practice, an interventional cardiologist often has to quickly and efficiently treat complex and challenging lesions in patients with acute coronary syndromes. The choice of the right guiding catheter and wire, the enhancement of guide catheter support by the use of stiffer wires or a “buddy” wire, deep intubation of the catheter, anchoring techniques and the use of guide extension catheter systems for facilitating equipment delivery, all contribute to the successful treatment of complex lesions in acute coronary syndrome patients . In this case report, the use of MC in the setting of primary PCI for ST elevation myocardial infarction (STEMI) is described.
2
Case description
A 59-year old man, known with hypertension, smoking habit and familiar history of coronary artery disease, was evaluated by the emergency services because of acute chest pain. The ECG revealed ST elevations in leads V1–V6 and pathological Q waves in leads V1–V4 and the patient was referred for urgent coronary angiography.
The patient was accepted for a primary intervention and the coronary angiogram (performed through the right femoral artery), revealed a proximally occluded left anterior descending (LAD) artery, a lesion of 90% at the distal segment of the left circumflex artery (LCx) and a lesion of 80% in the intermediate branch. No collateral flow towards the LAD territory was observed. The right coronary artery was also diffusively diseased with a proximal and distal stenosis of approximately 60%. The left coronary anatomy, with an LAD angulation of 90° to the left main (LM) and intermediate branch and a 180° angulation to the LCx, creating thus a cross-shaped anatomy in the right caudal projection ( Fig. 1 ), suggested that the PCI procedure would be challenging. The Judkins left 4.0 (JL4, Boston Scientific, Marlborough USA) guiding catheter was immediately replaced with an extra support guiding catheter (CLS4, Boston Scientific, Marlborough USA) and a wire was advanced to a marginal obtuse (MO) branch of the LCx branch to obtain a better backup (anchor). A BMW 0.014 coronary wire (Abbott Vascular, Santa Clara, California USA) was advanced proximally to the occluded LAD. The wire failed to cross the lesion as minimal manipulations resulted in the wire constantly flipping into the intermediate branch. Hydrophilic guide wires with extra tip weight like Pilot 50 (Abbott Vascular, Santa Clara, California USA) and Whisper MS (Abbott Vascular, Santa Clara, California USA) were subsequently applied with the same result ( Fig. 2 A ). In order to increase the penetrating power of the Whisper wire, a semi-compliant monorail balloon was attempted to advance up to a few millimeters before the tip of the wire. Unfortunately, the short stem of the LAD before the occlusion meant that the support the Whisper wire could provide for the advancement of the balloon was limited and the balloon proved quite rigid, forcing the wire to disengage from LAD. Next a Finecross MC (Terumo Interventional Systems, Tokyo, Japan) was applied. It followed relatively easy the Whisper wire over the extreme LM-LAD angulation up to just before its tip and just proximal to the occluded LAD ( Fig. 2 B). Having the support of the MC it was relatively easy to cross the occlusion and advance the wire into the distal LAD. The lesion was pre-dilated with a 2.5 × 20 mm semi-compliant balloon and finally two drug-eluting stents (DESs) were implanted in the proximal and mid-LAD (Resolute Onyx 3.5 × 22 mm and 2.75 × 26 mm respectively, Medtronic Inc., Minneapolis, USA). The LCx and intermediate branches were also treated with DES implantation in the same session. The final angiographic result is illustrated in Fig. 3 .
2
Case description
A 59-year old man, known with hypertension, smoking habit and familiar history of coronary artery disease, was evaluated by the emergency services because of acute chest pain. The ECG revealed ST elevations in leads V1–V6 and pathological Q waves in leads V1–V4 and the patient was referred for urgent coronary angiography.
The patient was accepted for a primary intervention and the coronary angiogram (performed through the right femoral artery), revealed a proximally occluded left anterior descending (LAD) artery, a lesion of 90% at the distal segment of the left circumflex artery (LCx) and a lesion of 80% in the intermediate branch. No collateral flow towards the LAD territory was observed. The right coronary artery was also diffusively diseased with a proximal and distal stenosis of approximately 60%. The left coronary anatomy, with an LAD angulation of 90° to the left main (LM) and intermediate branch and a 180° angulation to the LCx, creating thus a cross-shaped anatomy in the right caudal projection ( Fig. 1 ), suggested that the PCI procedure would be challenging. The Judkins left 4.0 (JL4, Boston Scientific, Marlborough USA) guiding catheter was immediately replaced with an extra support guiding catheter (CLS4, Boston Scientific, Marlborough USA) and a wire was advanced to a marginal obtuse (MO) branch of the LCx branch to obtain a better backup (anchor). A BMW 0.014 coronary wire (Abbott Vascular, Santa Clara, California USA) was advanced proximally to the occluded LAD. The wire failed to cross the lesion as minimal manipulations resulted in the wire constantly flipping into the intermediate branch. Hydrophilic guide wires with extra tip weight like Pilot 50 (Abbott Vascular, Santa Clara, California USA) and Whisper MS (Abbott Vascular, Santa Clara, California USA) were subsequently applied with the same result ( Fig. 2 A ). In order to increase the penetrating power of the Whisper wire, a semi-compliant monorail balloon was attempted to advance up to a few millimeters before the tip of the wire. Unfortunately, the short stem of the LAD before the occlusion meant that the support the Whisper wire could provide for the advancement of the balloon was limited and the balloon proved quite rigid, forcing the wire to disengage from LAD. Next a Finecross MC (Terumo Interventional Systems, Tokyo, Japan) was applied. It followed relatively easy the Whisper wire over the extreme LM-LAD angulation up to just before its tip and just proximal to the occluded LAD ( Fig. 2 B). Having the support of the MC it was relatively easy to cross the occlusion and advance the wire into the distal LAD. The lesion was pre-dilated with a 2.5 × 20 mm semi-compliant balloon and finally two drug-eluting stents (DESs) were implanted in the proximal and mid-LAD (Resolute Onyx 3.5 × 22 mm and 2.75 × 26 mm respectively, Medtronic Inc., Minneapolis, USA). The LCx and intermediate branches were also treated with DES implantation in the same session. The final angiographic result is illustrated in Fig. 3 .
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