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Efficacy of mother-child-grandchild technique: 4 F and 5 F inner catheters through mother guide catheter
Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter Takashi Ashikaga ⁎, Shunji Yoshikawa, Ken Kurihara, Mitsuaki Isobe Department of Cardiovascular Medicine, Tokyo Medical and Dental University
a r t i c l e
i n f o
Article history: Received 25 November 2013 Received in revised form 24 December 2013 Accepted 7 January 2014 Available online xxxx Keyword: Angioplasty Percutaneous coronary intervention
a b s t r a c t Stent delivery failure to the distal lesion was still encountered even after the introduction of mother–child technique using a 5 F or 4 F child catheter. A 5 F inner catheter with a length of 112 cm, and a 4 F inner catheter with a length of 122 cm enabled a novel mother–child–grandchild technique. In in vitro experiments, not only was backup support increased, but superior trackability could also be obtained with the mother–child–grandchild technique, over the mother–child technique. We describe the clinical data using this novel mother–child–grandchild technique to deliver a stent to the severely bended and/or calcified distal lesion. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Many stent delivery techniques have been developed for difficult situations [1,2]. An inner catheter is particularly helpful if increased backup support is needed during a procedure when the wire has already been inserted with difficulty through a guide catheter of conventional length. The principle role of an inner catheter is to combine the advantages afforded by the passive support of a large mother guide catheter, with the ability to insert a smaller inner catheter further into the target vessel, without damaging the arterial segment proximal to the lesion [3–6]. Recently, extra-deep engagement of a 4 F inner catheter enabled stent delivery even though the distal lesion in clinical practice. However, stent delivery failures have still been encountered after using a 4 F inner catheter [7–10]. Here we developed a mother–child–grandchild catheter system for difficult stent delivery cases.
2. Methods 2.1. Profile of guide system The length of the 5 F child catheter (i-works, Medikit, Japan) is 112 cm, 12 cm longer than a conventional guide catheter. The length of the 4 F grandchild catheter (i-works) is 122 cm. The inner diameter of the 4 F catheter is 1.26 mm (0.050 inch), and the inner diameter of the 5 F child catheter is 1.50 mm, (0.059 inch); larger than the outer
⁎ Corresponding author at: Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, 113-8519 Japan. Tel.: +81 3 5803 5231; fax: +81 3 5803 0133. E-mail address: [email protected] (T. Ashikaga).
diameter of the 4 F inner catheter (1.43 mm, 0.056 inch). The inner diameter of the mother guide catheter should be more than 1.80 mm (0.070 inch) to accommodate the outer diameter of a 5 F child catheter (1.70 mm, 0.067 inch). Thus, the mother–child–grandchild system is a method of inserting a 4 F grandchild catheter and a 5 F child catheter into a guide catheter larger than 6 F in order to increase backup support and trackability (Fig. 1A). 2.2. In vitro experiments The backup support of the guide catheter was measured in vitro using an experimental system. The artery model was filled with water kept at 37 °C. A guide catheter was engaged into the ostium of the artery model (Fig. 1B). Then a 2.5/15 mm balloon was pushed into the artery model along a standard 0.014-inch guidewire at a constant speed of 5 mm/s using a force gauge machine. The pushing force of the gauge machine represented the resistance of a balloon. The maximal backup support of the guide catheter was thus defined as the pushing force of the gauge machine when the guide catheter disengaged from the coronary system. The backup support was measured for 6 F alone, 5–6 system and 4–5–6 system using the same coronary artery model. Each measurement was repeated 5 times. In 5–6 system, the backup support was measured while protruding the 5 F catheter into the artery model out of the outer 6 F catheter by 10 mm. In 4–5–6 system, the backup support was measured while protruding the 4 F catheter into 5–6 system by 10 mm. Data were expressed as mean ± standard deviations. Comparison of continuous variables between equivalent groups was calculated by ANOVA. p value ≥ 0.05 was considered statistically insignificant. The trackability of the 6 F alone, 5–6 system and 4–5–6 system was assessed by the length (cm) between the ostium and the tip of catheter system.
1553-8389/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2014.01.003
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
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T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
Fig. 1. (A) Mother–child–grandchild system. (B) Backup support of a mother guide catheter, mother–child system and mother–child–grandchild system using in vitro measurement. While extending a child and grandchild catheter through a mother guide catheter, the stent delivery system was advanced using a force gauge machine. (C) The maximal backup support of the system was defined as the pushing force of the gauge machine when the mother guide catheter disengaged from the coronary system. Extending a 5 F child catheter out of a mother guide catheter was defined as 10 mm, and a 4 F grandchild catheter out of a mother guide catheter as 20 mm. (D) Trackability of guide system. The maximal trackability of the system was defined as the mother guide catheter disengaged from the coronary system.
3. Results Fig. 1C shows in vitro results of the backup support. The 5–6 system increased the backup support from 163.7 ± 16.6 gram force (gf) of a 6 F guide catheter alone to 96.4 ± 3.1 gf (p b 0.001). 4–5–6 system significantly increased backup support (417.0 ± 36.6 gf) compared to the 5–6 system and 6 F alone (p b 0.001). The trackability of 4–5–6 system was superior to that of 5–6 system (125 mm, 85 mm, respectively) (Fig. 1D).
4. Case report 4.1. Patient #1 A 75-year-old female was admitted to our hospital because of anteroseptal ST elevation myocardial infarction (STEMI). A bare metal stent was implanted at the proximal left anterior descending (LAD) coronary artery a month earlier. She underwent investigation for stable angina (Canadian Cardiovascular Society Class 3). The coronary angiogram revealed severe stenosis in the proximal and distal right coronary artery (RCA) (Fig. 2A). The RCA was engaged with a 7 F JR4.0 guide catheter (Mach I, Boston Scientific, Natick, MA) from the right
femoral approach. A 2.0/15 mm balloon (Tazuna, Terumo, Japan) could not be crossed at the distal RCA after crossing Runthrough NS guidewire (Terumo). This balloon could be crossed and predilated at the distal RCA after the deep engagement of a 112 cm 5 F inner catheter (i-works, Medikit, Japan) through a 7 F guide catheter using the mother–child technique. Since a 2.75/24 mm Nobori stent (Terumo) was unable to cross to the distal RCA (Fig. 2B), a 122 cm 4 F inner catheter (i-works) could be more deeply engaged through a 5 F inner catheter by using the anchor method, with the mother– child–grandchild technique (Fig. 2C). A 2.75/24 mm Nobori stent could then be easily deployed at the distal RCA (Fig. 2D). Since a 3.5/ 18 mm Nobori stent was unable to cross within a 4 F inner catheter because of its larger profile, the 4 F inner catheter was removed from the coronary system. A 3.5/18 mm Nobori stent could then be deployed at the proximal RCA through a 5 F inner catheter (Fig. 2E). The final angiogram revealed that the procedure was successful (Fig. 2F).
4.2. Patient #2 A 65-year-old male was admitted to our hospital because of anteroseptal STEMI. Emergent coronary angiogram showed total
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
Fig. 2. (A) Coronary angiogram showing severe lesions in mid and distal RCA. (B) A 112 cm 5 F inner catheter could be deep-engaged. A 2.75/24 mm Nobori could not be crossed to the distal RCA with a 5–7 system. (C, D) A 2.75/24 mm Nobori could be deployed at the distal RCA with a 4–5–7 system. (E) A 3.5/18 mm Nobori could be deployed at the mid RCA with a 5–7 system. (F) Final angiogram. White arrows, black arrows and black dotted arrows indicate the position of a 7 F, 5 F and 4 F guide catheter.
occlusion at the mid LAD (Fig. 3A). The left coronary artery (LCA) was engaged with a 6 F JL3.5 (Mach I) guide catheter from the right radial approach. Predilatation with a 2.0/15 mm balloon (Sprinter Legend, Medtronic Inc., Minneapolis, Minnesota) could be performed at the mid and distal LAD after crossing a Runthrough NS guidewire. A 2.5/ 28 mm ML-vision stent (Abbott, Santa Clara, USA) could not be crossed to the distal lesion even with the buddy wire technique using Neo's Rinate guidewire (Asahi Intec., Japan). A 5–6 system using a 122 m 5 F inner catheter (Dio, Goodman corp., Japan) was also ineffective. A 2.5/28 mm and a 2.5/12 mm ML-vision stent could be deployed at the mid LAD with 4–6 system using a 122 cm 4 F inner catheter (i-works) through a 6 F guide catheter. However, a 2.25/ 12 mm stent (ML-vision) could not be crossed to the distal LAD. Final angiogram showed TIMI III flow with the residual stenosis (Fig. 3B). He developed recurrent angina 6 months after coronary angioplasty. Diagnostic angiogram revealed the culprit to be restenosis of the LAD (Fig. 3C). The LCA was engaged with a 7 F CLS3.5 guide catheter (Mach I) from the right femoral approach. This lesion was crossed with a Runthrough NS guidewire. A 5 F inner catheter through a 7 F mother
3
Fig. 3. (A) Coronary angiogram showing total occlusion at the first PCI. (B) By using a 4– 6 system, two stents could be deployed at the mid LAD. Final angiogram at the first PCI. (C) Coronary angiogram showing in-stent restenosis at the mid and distal LAD at the second PCI. (D) By using a 5–7 system, a 2.25/16 mm EES could not be crossed to the distal LAD. (E) A 2.25/16 mm EES could be deployed at the distal LAD with 4–5–7 system. (F) Final angiogram at the second PCI. White arrows, black arrows and black dotted arrows indicate the position of 7 F, 5 F and 4 F guide catheter.
catheter was required for the passage of 2.0/15 mm balloon. After predilatation with this balloon, a 2.25/20 mm Promus Element (Boston Scientific) could not be crossed to the distal LAD (Fig. 3D). However, a 122 cm 4 F inner catheter could be more deeply engaged through a 112 cm 5 F inner catheter using the mother–child– grandchild technique. A 2.25/20 mm Promus Element could be easily deployed (Fig. 3E). A 2.5/22 mm and 2.5/18 mm Resolute Integrity (Medtronic) also could be deployed. A 2.5/13 mm balloon (Raiden, Kaneka, Japan) was employed for postdilatation. Final angiogram revealed that the procedure was successful (Fig. 3F). 5. Discussion Previous report showed that mother–child technique using a 5 F inner catheter had been introduced to improve backup support and effective as a distal stent delivery device [11]. Although extra deep intubation with a 5 F inner catheter facilitates a stent delivery by transversing proximal points of obstruction and by increasing backup support, a 5 F inner catheter often cannot be advanced into an
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
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T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
angulated calcified lesion because of its larger profile (outer diameter=1.73 mm) [5]. Recent advancements of a 4 F inner catheter enabled a distal stent delivery instead of a 5 F inner catheter in daily practice. Although the soft distal portion of the 4 F inner catheter can easily navigate the distal tortuous coronary vessel without vessel injury due to the smaller outer diameter of a 4 F inner catheter (1.43 mm), failures of stent delivery have still been encountered after using a 4 F inner catheter because of limited backup support [8]. Here we developed a novel stent delivery method as a mother–child– grandchild catheter system. Our data demonstrated that increased backup force could be obtained with a mother–child–grandchild system compared to a mother catheter alone and mother–child system in vitro experiments. In addition, extra deep engagement could be accomplished with a mother–child–grandchild system compared to a mother–child system. Since the previous 4 F and 5 F inner catheters were 120 cm or 122 cm in length, a 4 F inner catheter could not fit into a 5 F inner catheter. This novel mother–child– grandchild system, which consists of a 122 cm 4 F inner catheter and a 112 cm 5 F inner catheter, enables stent delivery within a 4 F inner catheter. Since the difference between a 5 F and 4 F inner catheter is small (10 cm), a hemostatic valve as a connector between the 5 F and 4 F inner catheter should be required for this system instead of Y-connector. As required with a mother–child technique using a 4 F inner catheter, care when introducing and withdrawing balloons and stents is considered to avoid drawing air into the catheter which can be injected distally. The type of drug eluting stent, which can be deployed within a 4 F inner catheter using a conventional 0.014-inch guidewire, has a diameter up to 3.5 mm, except for the Nobori. Most of bare metal stents up to 4.0 mm can be passed through a 4 F inner catheter. In addition, a 4 F inner catheter can be deeply engaged in the mother–child–grandchild technique, because the 4 F inner catheter can accomplish advancement of around 15 cm into the coronary system.
6. Conclusion Not only increased backup support but also extra-deep engagement of a 4 F inner catheter could be obtained with mother–child– grandchild technique in in vitro experiments. By using this technique, distal stent delivery could be more easily accomplished in severely elongated and/or calcified lesion. References [1] Ashikaga T, Sakurai K, Satoh Y. Tools and technique: stent delivery in distal lesion. EuroIntervention 2010;6:660–1. [2] Ashikaga T, Nishizaki M, Yamawake N. Difficult stent delivery: use of an aspiration catheter as a “sheath”. Catheter Cardiovasc Interv 2008;71:909–12. [3] Garcia-Garcia HM, Kukreja N, Daemon J, Shuzou T, Van Mieghem C, Gonzalo N, et al. Contemporary treatment of patients with chronic total occlusion: critical appraisal of different state of the art techniques and devices. EuroIntervention 2007;3:E1–9. [4] Shaukat A, Al-Bustami M, Ong PJ. Chronic total occlusion- use of a 5 French guiding catheter in a 6 French guiding catheter. J Invasive Cardiol 2008;20:317–8. [5] Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the Heartrail II catheter as a stent delivery catheter following failure of conventional technique. Catheter Cardiovasc Interv 2008;71:358–63. [6] Ashikaga T, Sakurai K, Satoh Y. Distal balloon deflation technique: a new method to facilitate entry of balloon catheter, stent and guiding catheter to distal lesion. Catheter Cardiovasc Interv 2010;75:356–61. [7] Hiwatashi A, Iwabuchi M, Yokoi H, Tayama S, Sakamoto T, Noda K, et al. PCI using a 4-Fr "child" guide catheter in a "mother" guide catheter: Kyushu Kiwami ST Registry. Catheter Cardiovasc Interv 2010;76:919–23. [8] Takeshita S, Shishido K, Sugitatsu K, Okamura N, Mizuno S, Yaginuma K, et al. In vitro and human studies of a 4 F double-coaxial technique (" Mother–Child" configuration) to facilitate stent implantation in resistant coronary vessels. Circ Cardiovasc Interv 2011;4:155–61. [9] Ashikaga T, Sakurai K, Satoh Y. A novel mother and child technique with a 4 F inner catheter based on proper alignment of both catheters. Catheter Cardiovasc Interv 2012;79:1004–8. [10] Ashikaga T, Sakurai K, Satoh Y, Inagaki H, Yoshikawa S, Kurihara K, et al. Mother– child technique using a novel 4 F inner catheter. Eurointervention 2014 [in press]. [11] Takahashi S, Saito S, Tanaka S, Miyashita Y, Shiono T, Arai F, et al. New method to increase a backup support of a 6 French guiding catheter. Catheter Cardiovasc Interv 2004;63:452–6.
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter Takashi Ashikaga ⁎, Shunji Yoshikawa, Ken Kurihara, Mitsuaki Isobe Department of Cardiovascular Medicine, Tokyo Medical and Dental University
a r t i c l e
i n f o
Article history: Received 25 November 2013 Received in revised form 24 December 2013 Accepted 7 January 2014 Available online xxxx Keyword: Angioplasty Percutaneous coronary intervention
a b s t r a c t Stent delivery failure to the distal lesion was still encountered even after the introduction of mother–child technique using a 5 F or 4 F child catheter. A 5 F inner catheter with a length of 112 cm, and a 4 F inner catheter with a length of 122 cm enabled a novel mother–child–grandchild technique. In in vitro experiments, not only was backup support increased, but superior trackability could also be obtained with the mother–child–grandchild technique, over the mother–child technique. We describe the clinical data using this novel mother–child–grandchild technique to deliver a stent to the severely bended and/or calcified distal lesion. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Many stent delivery techniques have been developed for difficult situations [1,2]. An inner catheter is particularly helpful if increased backup support is needed during a procedure when the wire has already been inserted with difficulty through a guide catheter of conventional length. The principle role of an inner catheter is to combine the advantages afforded by the passive support of a large mother guide catheter, with the ability to insert a smaller inner catheter further into the target vessel, without damaging the arterial segment proximal to the lesion [3–6]. Recently, extra-deep engagement of a 4 F inner catheter enabled stent delivery even though the distal lesion in clinical practice. However, stent delivery failures have still been encountered after using a 4 F inner catheter [7–10]. Here we developed a mother–child–grandchild catheter system for difficult stent delivery cases.
2. Methods 2.1. Profile of guide system The length of the 5 F child catheter (i-works, Medikit, Japan) is 112 cm, 12 cm longer than a conventional guide catheter. The length of the 4 F grandchild catheter (i-works) is 122 cm. The inner diameter of the 4 F catheter is 1.26 mm (0.050 inch), and the inner diameter of the 5 F child catheter is 1.50 mm, (0.059 inch); larger than the outer
⁎ Corresponding author at: Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, 113-8519 Japan. Tel.: +81 3 5803 5231; fax: +81 3 5803 0133. E-mail address: [email protected] (T. Ashikaga).
diameter of the 4 F inner catheter (1.43 mm, 0.056 inch). The inner diameter of the mother guide catheter should be more than 1.80 mm (0.070 inch) to accommodate the outer diameter of a 5 F child catheter (1.70 mm, 0.067 inch). Thus, the mother–child–grandchild system is a method of inserting a 4 F grandchild catheter and a 5 F child catheter into a guide catheter larger than 6 F in order to increase backup support and trackability (Fig. 1A). 2.2. In vitro experiments The backup support of the guide catheter was measured in vitro using an experimental system. The artery model was filled with water kept at 37 °C. A guide catheter was engaged into the ostium of the artery model (Fig. 1B). Then a 2.5/15 mm balloon was pushed into the artery model along a standard 0.014-inch guidewire at a constant speed of 5 mm/s using a force gauge machine. The pushing force of the gauge machine represented the resistance of a balloon. The maximal backup support of the guide catheter was thus defined as the pushing force of the gauge machine when the guide catheter disengaged from the coronary system. The backup support was measured for 6 F alone, 5–6 system and 4–5–6 system using the same coronary artery model. Each measurement was repeated 5 times. In 5–6 system, the backup support was measured while protruding the 5 F catheter into the artery model out of the outer 6 F catheter by 10 mm. In 4–5–6 system, the backup support was measured while protruding the 4 F catheter into 5–6 system by 10 mm. Data were expressed as mean ± standard deviations. Comparison of continuous variables between equivalent groups was calculated by ANOVA. p value ≥ 0.05 was considered statistically insignificant. The trackability of the 6 F alone, 5–6 system and 4–5–6 system was assessed by the length (cm) between the ostium and the tip of catheter system.
1553-8389/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2014.01.003
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
2
T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
Fig. 1. (A) Mother–child–grandchild system. (B) Backup support of a mother guide catheter, mother–child system and mother–child–grandchild system using in vitro measurement. While extending a child and grandchild catheter through a mother guide catheter, the stent delivery system was advanced using a force gauge machine. (C) The maximal backup support of the system was defined as the pushing force of the gauge machine when the mother guide catheter disengaged from the coronary system. Extending a 5 F child catheter out of a mother guide catheter was defined as 10 mm, and a 4 F grandchild catheter out of a mother guide catheter as 20 mm. (D) Trackability of guide system. The maximal trackability of the system was defined as the mother guide catheter disengaged from the coronary system.
3. Results Fig. 1C shows in vitro results of the backup support. The 5–6 system increased the backup support from 163.7 ± 16.6 gram force (gf) of a 6 F guide catheter alone to 96.4 ± 3.1 gf (p b 0.001). 4–5–6 system significantly increased backup support (417.0 ± 36.6 gf) compared to the 5–6 system and 6 F alone (p b 0.001). The trackability of 4–5–6 system was superior to that of 5–6 system (125 mm, 85 mm, respectively) (Fig. 1D).
4. Case report 4.1. Patient #1 A 75-year-old female was admitted to our hospital because of anteroseptal ST elevation myocardial infarction (STEMI). A bare metal stent was implanted at the proximal left anterior descending (LAD) coronary artery a month earlier. She underwent investigation for stable angina (Canadian Cardiovascular Society Class 3). The coronary angiogram revealed severe stenosis in the proximal and distal right coronary artery (RCA) (Fig. 2A). The RCA was engaged with a 7 F JR4.0 guide catheter (Mach I, Boston Scientific, Natick, MA) from the right
femoral approach. A 2.0/15 mm balloon (Tazuna, Terumo, Japan) could not be crossed at the distal RCA after crossing Runthrough NS guidewire (Terumo). This balloon could be crossed and predilated at the distal RCA after the deep engagement of a 112 cm 5 F inner catheter (i-works, Medikit, Japan) through a 7 F guide catheter using the mother–child technique. Since a 2.75/24 mm Nobori stent (Terumo) was unable to cross to the distal RCA (Fig. 2B), a 122 cm 4 F inner catheter (i-works) could be more deeply engaged through a 5 F inner catheter by using the anchor method, with the mother– child–grandchild technique (Fig. 2C). A 2.75/24 mm Nobori stent could then be easily deployed at the distal RCA (Fig. 2D). Since a 3.5/ 18 mm Nobori stent was unable to cross within a 4 F inner catheter because of its larger profile, the 4 F inner catheter was removed from the coronary system. A 3.5/18 mm Nobori stent could then be deployed at the proximal RCA through a 5 F inner catheter (Fig. 2E). The final angiogram revealed that the procedure was successful (Fig. 2F).
4.2. Patient #2 A 65-year-old male was admitted to our hospital because of anteroseptal STEMI. Emergent coronary angiogram showed total
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
Fig. 2. (A) Coronary angiogram showing severe lesions in mid and distal RCA. (B) A 112 cm 5 F inner catheter could be deep-engaged. A 2.75/24 mm Nobori could not be crossed to the distal RCA with a 5–7 system. (C, D) A 2.75/24 mm Nobori could be deployed at the distal RCA with a 4–5–7 system. (E) A 3.5/18 mm Nobori could be deployed at the mid RCA with a 5–7 system. (F) Final angiogram. White arrows, black arrows and black dotted arrows indicate the position of a 7 F, 5 F and 4 F guide catheter.
occlusion at the mid LAD (Fig. 3A). The left coronary artery (LCA) was engaged with a 6 F JL3.5 (Mach I) guide catheter from the right radial approach. Predilatation with a 2.0/15 mm balloon (Sprinter Legend, Medtronic Inc., Minneapolis, Minnesota) could be performed at the mid and distal LAD after crossing a Runthrough NS guidewire. A 2.5/ 28 mm ML-vision stent (Abbott, Santa Clara, USA) could not be crossed to the distal lesion even with the buddy wire technique using Neo's Rinate guidewire (Asahi Intec., Japan). A 5–6 system using a 122 m 5 F inner catheter (Dio, Goodman corp., Japan) was also ineffective. A 2.5/28 mm and a 2.5/12 mm ML-vision stent could be deployed at the mid LAD with 4–6 system using a 122 cm 4 F inner catheter (i-works) through a 6 F guide catheter. However, a 2.25/ 12 mm stent (ML-vision) could not be crossed to the distal LAD. Final angiogram showed TIMI III flow with the residual stenosis (Fig. 3B). He developed recurrent angina 6 months after coronary angioplasty. Diagnostic angiogram revealed the culprit to be restenosis of the LAD (Fig. 3C). The LCA was engaged with a 7 F CLS3.5 guide catheter (Mach I) from the right femoral approach. This lesion was crossed with a Runthrough NS guidewire. A 5 F inner catheter through a 7 F mother
3
Fig. 3. (A) Coronary angiogram showing total occlusion at the first PCI. (B) By using a 4– 6 system, two stents could be deployed at the mid LAD. Final angiogram at the first PCI. (C) Coronary angiogram showing in-stent restenosis at the mid and distal LAD at the second PCI. (D) By using a 5–7 system, a 2.25/16 mm EES could not be crossed to the distal LAD. (E) A 2.25/16 mm EES could be deployed at the distal LAD with 4–5–7 system. (F) Final angiogram at the second PCI. White arrows, black arrows and black dotted arrows indicate the position of 7 F, 5 F and 4 F guide catheter.
catheter was required for the passage of 2.0/15 mm balloon. After predilatation with this balloon, a 2.25/20 mm Promus Element (Boston Scientific) could not be crossed to the distal LAD (Fig. 3D). However, a 122 cm 4 F inner catheter could be more deeply engaged through a 112 cm 5 F inner catheter using the mother–child– grandchild technique. A 2.25/20 mm Promus Element could be easily deployed (Fig. 3E). A 2.5/22 mm and 2.5/18 mm Resolute Integrity (Medtronic) also could be deployed. A 2.5/13 mm balloon (Raiden, Kaneka, Japan) was employed for postdilatation. Final angiogram revealed that the procedure was successful (Fig. 3F). 5. Discussion Previous report showed that mother–child technique using a 5 F inner catheter had been introduced to improve backup support and effective as a distal stent delivery device [11]. Although extra deep intubation with a 5 F inner catheter facilitates a stent delivery by transversing proximal points of obstruction and by increasing backup support, a 5 F inner catheter often cannot be advanced into an
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003
4
T. Ashikaga et al. / Cardiovascular Revascularization Medicine xxx (2014) xxx–xxx
angulated calcified lesion because of its larger profile (outer diameter=1.73 mm) [5]. Recent advancements of a 4 F inner catheter enabled a distal stent delivery instead of a 5 F inner catheter in daily practice. Although the soft distal portion of the 4 F inner catheter can easily navigate the distal tortuous coronary vessel without vessel injury due to the smaller outer diameter of a 4 F inner catheter (1.43 mm), failures of stent delivery have still been encountered after using a 4 F inner catheter because of limited backup support [8]. Here we developed a novel stent delivery method as a mother–child– grandchild catheter system. Our data demonstrated that increased backup force could be obtained with a mother–child–grandchild system compared to a mother catheter alone and mother–child system in vitro experiments. In addition, extra deep engagement could be accomplished with a mother–child–grandchild system compared to a mother–child system. Since the previous 4 F and 5 F inner catheters were 120 cm or 122 cm in length, a 4 F inner catheter could not fit into a 5 F inner catheter. This novel mother–child– grandchild system, which consists of a 122 cm 4 F inner catheter and a 112 cm 5 F inner catheter, enables stent delivery within a 4 F inner catheter. Since the difference between a 5 F and 4 F inner catheter is small (10 cm), a hemostatic valve as a connector between the 5 F and 4 F inner catheter should be required for this system instead of Y-connector. As required with a mother–child technique using a 4 F inner catheter, care when introducing and withdrawing balloons and stents is considered to avoid drawing air into the catheter which can be injected distally. The type of drug eluting stent, which can be deployed within a 4 F inner catheter using a conventional 0.014-inch guidewire, has a diameter up to 3.5 mm, except for the Nobori. Most of bare metal stents up to 4.0 mm can be passed through a 4 F inner catheter. In addition, a 4 F inner catheter can be deeply engaged in the mother–child–grandchild technique, because the 4 F inner catheter can accomplish advancement of around 15 cm into the coronary system.
6. Conclusion Not only increased backup support but also extra-deep engagement of a 4 F inner catheter could be obtained with mother–child– grandchild technique in in vitro experiments. By using this technique, distal stent delivery could be more easily accomplished in severely elongated and/or calcified lesion. References [1] Ashikaga T, Sakurai K, Satoh Y. Tools and technique: stent delivery in distal lesion. EuroIntervention 2010;6:660–1. [2] Ashikaga T, Nishizaki M, Yamawake N. Difficult stent delivery: use of an aspiration catheter as a “sheath”. Catheter Cardiovasc Interv 2008;71:909–12. [3] Garcia-Garcia HM, Kukreja N, Daemon J, Shuzou T, Van Mieghem C, Gonzalo N, et al. Contemporary treatment of patients with chronic total occlusion: critical appraisal of different state of the art techniques and devices. EuroIntervention 2007;3:E1–9. [4] Shaukat A, Al-Bustami M, Ong PJ. Chronic total occlusion- use of a 5 French guiding catheter in a 6 French guiding catheter. J Invasive Cardiol 2008;20:317–8. [5] Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the Heartrail II catheter as a stent delivery catheter following failure of conventional technique. Catheter Cardiovasc Interv 2008;71:358–63. [6] Ashikaga T, Sakurai K, Satoh Y. Distal balloon deflation technique: a new method to facilitate entry of balloon catheter, stent and guiding catheter to distal lesion. Catheter Cardiovasc Interv 2010;75:356–61. [7] Hiwatashi A, Iwabuchi M, Yokoi H, Tayama S, Sakamoto T, Noda K, et al. PCI using a 4-Fr "child" guide catheter in a "mother" guide catheter: Kyushu Kiwami ST Registry. Catheter Cardiovasc Interv 2010;76:919–23. [8] Takeshita S, Shishido K, Sugitatsu K, Okamura N, Mizuno S, Yaginuma K, et al. In vitro and human studies of a 4 F double-coaxial technique (" Mother–Child" configuration) to facilitate stent implantation in resistant coronary vessels. Circ Cardiovasc Interv 2011;4:155–61. [9] Ashikaga T, Sakurai K, Satoh Y. A novel mother and child technique with a 4 F inner catheter based on proper alignment of both catheters. Catheter Cardiovasc Interv 2012;79:1004–8. [10] Ashikaga T, Sakurai K, Satoh Y, Inagaki H, Yoshikawa S, Kurihara K, et al. Mother– child technique using a novel 4 F inner catheter. Eurointervention 2014 [in press]. [11] Takahashi S, Saito S, Tanaka S, Miyashita Y, Shiono T, Arai F, et al. New method to increase a backup support of a 6 French guiding catheter. Catheter Cardiovasc Interv 2004;63:452–6.
Please cite this article as: Ashikaga T, et al, Efficacy of mother–child–grandchild technique: 4 F and 5 F inner catheters through mother guide catheter, Cardiovasc Revasc Med (2014), http://dx.doi.org/10.1016/j.carrev.2014.01.003