Abstract
Patients with chronic kidney disease (CKD) undergoing PCI are at very high risk from the development of contrast-induced nephropathy (CIN). Development of CIN in patients with CKD is an independent predictor of in-hospital and 1-year mortality, and contrast load is an important predictor for CIN development. The Terumo ‘five-in-six’ system involves insertion of an extra-length, 5F Terumo guide catheter (Heartrail, Terumo) into a standard 6F guide catheter so that the tip protrudes beyond the 6F guide. We describe the use of this system to facilitate extra-deep selective coronary intubation and opacification of native coronary vessels in order to minimize contrast use in patients with severe renal dysfunction, thereby reducing the potential for CIN development. This technique should be considered in patients at high risk from developing renal complications post PCI.
1
Introduction
Chronic kidney disease (CKD) is one of the most important predictors of an adverse outcome in patients undergoing percutaneous coronary intervention (PCI) with in-hospital and 1-year mortality rates reported at 4.2% and 25.7% among patients with CKD undergoing PCI, respectively . Furthermore, patients undergoing PCI with CKD are at increased risk of contrast-induced nephropathy (CIN) development with rates as high as 20–30% having been reported in a large case series . Development of CIN in patients with CKD is independently associated with a greater than twofold increase in 1-year mortality rate (OR 2.37, 95% CI 1.63–3.44) post PCI, and contrast load use is an important predictor for the development of CIN . The Heartrail II catheter is an extra-length soft-tipped 5 F catheter that fits within a standard 6F catheter and can extend up to 16 cm distal to the tip [the ‘mother-and-child’ or ‘five-in-six’ (5-in-6) system]. We have previously reported the use of the Heartrail catheter as a distal stent delivery device by means of extra-deep intubation of native and graft vessels.
We describe the use of the Heartrail 5-in-6 system to achieve deep selective intubation and opacification of native coronary vessels in both the acute and elective setting in order to minimize contrast use in patients with severe renal dysfunction, thereby reducing the potential for CIN development. Two such cases in patients with Stage 5 CKD are presented below.
2
Cases
2.1
Case 1
In the first case, a 52-year-old male with an absent right kidney and chronic renal failure (creatinine 449 μmol/l or 5.08 mg/dl) with an estimated GFR of 15 ml/min was transferred for primary PCI with a lateral STEMI. The left circumflex was occluded proximally ( Fig. 1 A ). A power backup (PBU) 3.5 sheathless guide (6.5F) was used to cannulate the left coronary system, and a Heartrail catheter was used to achieve selective intubation to a depth of 3 cm of the circumflex in order to allow selective opacification of the circumflex and to minimize contrast use ( Fig. 1 B). The lesion was predilated multiple times with a 2.5×12-mm Voyager balloon ( Fig. 1 C) and a 2.5×28-mm Promus stent was deployed distally ( Fig. 1 D). There appeared to be some haziness at the proximal edge of the stent; therefore a further 2.5×8-mm Promus stent was deployed proximally. Both stents were postdilated with a 2.75×15-mm Mercury noncompliant balloon to high pressures. The final result is illustrated in Fig. 1 E. Selective cannulation of the circumflex using the Heartrail ensured adequate opacification of the vessel throughout the procedure with minimal contrast use (80 ml contrast in total: 30 ml for PCI and 50 ml for diagnostic coronary angiography).
2.2
Case 2
In a second elective case, a 71-year-old male with severely limiting angina and chronic renal failure (creatinine 505 μmol /l or 5.71 mg/dl) with an estimated GFR of 10 ml/min was admitted for PCI to a heavily calcified RCA in which there was a severe lesion in the PDA and a further ostial lesion which caused significant pressure damping on cannulation with the catheter ( Fig. 2 A ). A previous attempt at PCI to the PDA lesion by another operator had failed due to the inability to cross the lesion with a balloon to enable predilation. A 6.5F JR4 sheathless guide catheter was used to cannulate the RCA, and a Heartrail catheter was used to facilitate deep intubation of the RCA to a depth of 7.5 cm just proximal to the PDA lesion enabling visualization with minimal contrast use ( Fig. 2 B and C). The PDA lesion was crossed with an extra-supportive wire, and repeated initial attempts to cross the lesion with an Avion 1.25-mm balloon ( Avion Plus, Invatec) failed. Eventually, the lesion was crossed with a Riyujin 1.25-mm balloon (Terumo, Japan) and the lesion was subsequently predilated with multiple 1.5- and 2-mm compliant and noncompliant balloons to high pressure. In view of the small vessel size a stent was not used. Finally, a Taxus 3×16-mm stent was used at the ostium of the RCA with the final result illustrated in Fig. 2 D. Despite the severe nature of the PDA lesion resulting in utilization of multiple balloons to cross and predilate the lesion, the procedure was performed with only 90 ml of contrast used. In both cases, renal function remained stable and CIN was not observed. Both patients were discharged without complications and remain well at follow-up.
2.3
Heartrail Catheter technique
The Heartrail ‘5-in-6 system’ involves insertion of an extra-length 5F soft-tipped catheter (Heartrail, Terumo, Japan) into a standard 6F guide catheter so that the distal tip of the 5F catheter can extend or ‘telescope’ up to 16 cm beyond the tip of the 6F catheter. The Heartrail catheter is designed to fit within 6F or larger guiding catheters with an internal lumen of at least 0.071 in. In this series, we used the catheter without difficulty within Asahi sheathless 6.5F guide catheters (ASAHI Intecc, Aichi, Japan) that have internal lumens of 0.070 in. and have previously described its use in 6F conventional guide catheters . We have previously described our technique enabling extra-deep intubation of coronary vessels with the Heartrail catheter . Briefly, the haemostatic valve was disconnected from the guide catheter and the Heartrail device was passed through the guide catheter into the target vessel over a coronary wire to achieve the necessary intubation depth required. The haemostatic valve was then reattached to the end of the Heartrail catheter, and the interventional procedure was performed in the usual manner through the haemostatic valve ( Fig. 3A and B ). We have now performed over 150 Heartrail procedures at our centre and have never encountered bleed back between the two catheters. The Heartrail catheter has a larger internal lumen than other 5F catheters at 0.059 in. and are able to advance drug-eluting stents of up to 4 mm in diameter within this catheter without resistance and are able to advance smaller diameter stents with two support wires in situ .
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