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Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary intervention of the right coronary artery
CARREV-01553; No of Pages 2 Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary intervention of the right coronary artery☆ George Latsios ⁎,1, Konstantinos Toutouzas 1, Antonios Karanasos, Dimitrios Tousoulis 1st Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 23 January 2019 Received in revised form 19 March 2019 Accepted 25 March 2019 Available online xxxx Keywords: Percutaneous coronary intervention Rotational atherectomy Guide catheters Coronary calcification
a b s t r a c t We describe a case of an 84-year old gentleman undergoing PCI of a heavily calcified and stenotic right coronary artery. Rotational atherectomy was employed, but due to difficulties in wiring and burr advancement, extra deep guide-catheter intubation was used to provide support and facilitate advancement of the burr and subsequent stent deployment. An approach with careful extra deep guide-catheter intubation in rotablation is an option that might be considered for selected cases with severely stenotic, calcified, angulated lesions. © 2019 Elsevier Inc. All rights reserved.
1. Case report An 84-year old gentleman was referred for percutaneous coronary intervention (PCI) of the right coronary artery (RCA) due to stable angina CCS III, despite optimal medical treatment. He had extensive inferior wall ischemia by dobutamine stress echocardiography. His coronary angiography had disclosed multiple severely calcified and stenotic lesions at the distal RCA (Fig. 1A – Video 1). An attempt for PCI in another hospital was unsuccessful, because no balloon (not even 1.25 mm) would cross the stenosis. A new attempt was performed transfemorally with adjuvant use of rotational atherectomy (Rotablator; Boston Scientific, Massachusetts, USA). A temporary pacing wire was inserted and a 6-French Judkins Right 4 (JR4) guide-catheter cannulated the RCA ostium. Using a Finecross (Terumo, Japan) microcatheter, a hydrophilic angioplasty wire crossed the stenosis and was exchanged for Rotawire (Boston Scientific). Consequently, however, the 1.25 mm Rotaburr (Boston Scientific) could only be advanced to mid RCA. Then, with a pushing and clockwise maneuver, we gently advanced the JR4 guide-catheter over the Rotaburr catheter (as a “railway”), very deep into the RCA, while monitoring the pressure waveform for signs of damping or ventricularization and avoiding contrast injection (Fig. 1B – Video 2). The patient remained angina-free without ECG changes or hemodynamic compromise, despite continuous deep engagement, and the
☆ Conflicts of interest: The authors have no conflicts of interest to declare. ⁎ Corresponding author at: Alexandroupoleos 9, 11527 Athens, Greece. E-mail address: [email protected] (G. Latsios). 1 The two first authors (GL and KT) have equally contributed to the paper.
pressure waveform remained stable. Rotational atherectomy could then be performed with 1.25 mm and 1.5 mm burrs, and predilatation with 2.0 mm and 2.5 mm non-compliant balloons at high pressures followed. Three drug-eluting stents 2.5 × 26 mm, 2.5 × 30 mm and 3.0 × 34 mm (Resolute Integrity; Medtronic, Santa Rosa, CA, USA) were subsequently implanted with overlap from distally to proximally; the two distal with deep guide-catheter engagement and the proximal after slight guide catheter withdrawal. The final angiographic result was excellent (Fig. 1C–D – Videos 3–4). 2. Discussion We describe a case where extra deep guide-catheter intubation was used to advance the Rotaburr. Deep catheter intubation has been suggested to increase catheter backup in challenging cases with tortuous arteries [1–3]. However, implementation of this technique has not been reported thus far for rotational atherectomy. Although several alternatives could be applied, we dismissed them. Specifically, since a 7 French or an Amplatz Left guide-catheter that might have increased passive guide support had not been used from the beginning, performing at this stage an exchange for such a catheter with complete system removal would have turned into a starting-again scenario, in an already very difficult to wire stenosis. The use of guide-catheter extension catheters has been used in very few selected cases [4], but the catheter would have to be advanced over the slim 0.009″ Rotawire and would hardly accommodate just the 1.25 mm burr. We opted therefore for the careful extra deep guide-catheter intubation to facilitate the Rotaburr advancement, while cautiously observing pressure waveform and avoiding contrast injection which could possibly cause a hydraulic
Please cite this article as: G. Latsios, K. Toutouzas, A. Karanasos, et al., Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary interv..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.020
2
G. Latsios et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 1. A. Diagnostic angiography of the right coronary artery, showing multiple calcified subtotal stenoses (black arrows). Dotted white line indicates the right coronary cusp – right coronary ostium. B. Extra deep intubation of the Judkins Right 4 guiding catheter (white arrow) to allow for advancement of the 1.25 Rotaburr (black arrow) to the distality of the vessel. Dotted white line indicates the right coronary cusp – right coronary ostium. C. and D. Final result after stent deployment.
dissection. The successful advancement of the Rotaburr enabled sufficient lesion preparation and successful stent deployment. An approach with careful extra deep guide-catheter intubation in rotablation is an acceptable option for selected cases with severely stenotic, calcified, angulated lesions of the RCA. Supplementary data to this article can be found online at https://doi. org/10.1016/j.carrev.2019.03.020.
[2] Von Sohsten R, Oz R, Marone G, McCormick DJ. Deep intubation of 6 French guiding catheters for transradial coronary interventions. J Invasive Cardiol 1998;10:198–202. [3] Bagur R, Gleeton O, Rinfret S, De Larochelliere R, Bertrand OF, Rodes-Cabau J. Transradial extra deep coronary intubation with a guide catheter for direct thromboaspiration in acute myocardial infarction. Int J Cardiol 2012;158:e32–4. [4] Costanzo P, Aznaouridis K, Hoye A, Alahmar A. GuideLiner-facilitated rotational atherectomy in calcified right coronary artery: the “child” makes the difference. JACC Cardiovasc Interv 2016;9:e47–8.
References [1] Saeed B, Banerjee S, Brilakis ES. Percutaneous coronary intervention in tortuous coronary arteries: associated complications and strategies to improve success. J Interv Cardiol 2008;21:504–11.
Please cite this article as: G. Latsios, K. Toutouzas, A. Karanasos, et al., Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary interv..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.020
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary intervention of the right coronary artery☆ George Latsios ⁎,1, Konstantinos Toutouzas 1, Antonios Karanasos, Dimitrios Tousoulis 1st Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 23 January 2019 Received in revised form 19 March 2019 Accepted 25 March 2019 Available online xxxx Keywords: Percutaneous coronary intervention Rotational atherectomy Guide catheters Coronary calcification
a b s t r a c t We describe a case of an 84-year old gentleman undergoing PCI of a heavily calcified and stenotic right coronary artery. Rotational atherectomy was employed, but due to difficulties in wiring and burr advancement, extra deep guide-catheter intubation was used to provide support and facilitate advancement of the burr and subsequent stent deployment. An approach with careful extra deep guide-catheter intubation in rotablation is an option that might be considered for selected cases with severely stenotic, calcified, angulated lesions. © 2019 Elsevier Inc. All rights reserved.
1. Case report An 84-year old gentleman was referred for percutaneous coronary intervention (PCI) of the right coronary artery (RCA) due to stable angina CCS III, despite optimal medical treatment. He had extensive inferior wall ischemia by dobutamine stress echocardiography. His coronary angiography had disclosed multiple severely calcified and stenotic lesions at the distal RCA (Fig. 1A – Video 1). An attempt for PCI in another hospital was unsuccessful, because no balloon (not even 1.25 mm) would cross the stenosis. A new attempt was performed transfemorally with adjuvant use of rotational atherectomy (Rotablator; Boston Scientific, Massachusetts, USA). A temporary pacing wire was inserted and a 6-French Judkins Right 4 (JR4) guide-catheter cannulated the RCA ostium. Using a Finecross (Terumo, Japan) microcatheter, a hydrophilic angioplasty wire crossed the stenosis and was exchanged for Rotawire (Boston Scientific). Consequently, however, the 1.25 mm Rotaburr (Boston Scientific) could only be advanced to mid RCA. Then, with a pushing and clockwise maneuver, we gently advanced the JR4 guide-catheter over the Rotaburr catheter (as a “railway”), very deep into the RCA, while monitoring the pressure waveform for signs of damping or ventricularization and avoiding contrast injection (Fig. 1B – Video 2). The patient remained angina-free without ECG changes or hemodynamic compromise, despite continuous deep engagement, and the
☆ Conflicts of interest: The authors have no conflicts of interest to declare. ⁎ Corresponding author at: Alexandroupoleos 9, 11527 Athens, Greece. E-mail address: [email protected] (G. Latsios). 1 The two first authors (GL and KT) have equally contributed to the paper.
pressure waveform remained stable. Rotational atherectomy could then be performed with 1.25 mm and 1.5 mm burrs, and predilatation with 2.0 mm and 2.5 mm non-compliant balloons at high pressures followed. Three drug-eluting stents 2.5 × 26 mm, 2.5 × 30 mm and 3.0 × 34 mm (Resolute Integrity; Medtronic, Santa Rosa, CA, USA) were subsequently implanted with overlap from distally to proximally; the two distal with deep guide-catheter engagement and the proximal after slight guide catheter withdrawal. The final angiographic result was excellent (Fig. 1C–D – Videos 3–4). 2. Discussion We describe a case where extra deep guide-catheter intubation was used to advance the Rotaburr. Deep catheter intubation has been suggested to increase catheter backup in challenging cases with tortuous arteries [1–3]. However, implementation of this technique has not been reported thus far for rotational atherectomy. Although several alternatives could be applied, we dismissed them. Specifically, since a 7 French or an Amplatz Left guide-catheter that might have increased passive guide support had not been used from the beginning, performing at this stage an exchange for such a catheter with complete system removal would have turned into a starting-again scenario, in an already very difficult to wire stenosis. The use of guide-catheter extension catheters has been used in very few selected cases [4], but the catheter would have to be advanced over the slim 0.009″ Rotawire and would hardly accommodate just the 1.25 mm burr. We opted therefore for the careful extra deep guide-catheter intubation to facilitate the Rotaburr advancement, while cautiously observing pressure waveform and avoiding contrast injection which could possibly cause a hydraulic
Please cite this article as: G. Latsios, K. Toutouzas, A. Karanasos, et al., Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary interv..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.020
2
G. Latsios et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 1. A. Diagnostic angiography of the right coronary artery, showing multiple calcified subtotal stenoses (black arrows). Dotted white line indicates the right coronary cusp – right coronary ostium. B. Extra deep intubation of the Judkins Right 4 guiding catheter (white arrow) to allow for advancement of the 1.25 Rotaburr (black arrow) to the distality of the vessel. Dotted white line indicates the right coronary cusp – right coronary ostium. C. and D. Final result after stent deployment.
dissection. The successful advancement of the Rotaburr enabled sufficient lesion preparation and successful stent deployment. An approach with careful extra deep guide-catheter intubation in rotablation is an acceptable option for selected cases with severely stenotic, calcified, angulated lesions of the RCA. Supplementary data to this article can be found online at https://doi. org/10.1016/j.carrev.2019.03.020.
[2] Von Sohsten R, Oz R, Marone G, McCormick DJ. Deep intubation of 6 French guiding catheters for transradial coronary interventions. J Invasive Cardiol 1998;10:198–202. [3] Bagur R, Gleeton O, Rinfret S, De Larochelliere R, Bertrand OF, Rodes-Cabau J. Transradial extra deep coronary intubation with a guide catheter for direct thromboaspiration in acute myocardial infarction. Int J Cardiol 2012;158:e32–4. [4] Costanzo P, Aznaouridis K, Hoye A, Alahmar A. GuideLiner-facilitated rotational atherectomy in calcified right coronary artery: the “child” makes the difference. JACC Cardiovasc Interv 2016;9:e47–8.
References [1] Saeed B, Banerjee S, Brilakis ES. Percutaneous coronary intervention in tortuous coronary arteries: associated complications and strategies to improve success. J Interv Cardiol 2008;21:504–11.
Please cite this article as: G. Latsios, K. Toutouzas, A. Karanasos, et al., Use of extra deep guide-catheter intubation for rotablation-facilitated percutaneous coronary interv..., Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.03.020