Bonus Online Case: A Novel Use of Dio Catheter for Delivery of Rotational Atherectomy Burr in Tortuous Coronary Artery

Abstract

A 70-year-old female was admitted to our emergency room with chest and back pain. Diagnosis was ST-elevation myocardial infarction and coronary angiogram demonstrated a subtotal occlusion with TIMI-2 flow at the distal lesion in a significantly tortuous right coronary artery (RCA). We attempted percutaneous coronary intervention for the distal RCA. After crossing the stenosis with a floppy wire, we could not reach the lesion with a balloon because of proximal tortuosity. Therefore, we advanced a balloon with the mother-and-child technique (MCT) with a deep-seated Guidezilla (Boston Scientific). A repeated high-pressure dilatation could not resolve the stenosis due to heavy calcification. Intravascular sonography confirmed that calcification had spread circumferentially. We decided to use rotational atherectomy (RA) (Boston Scientific). However, it was difficult to advance a 1.25 mm RA burr because of the proximal tortuosity. Next, MCT was used with a Guidezilla. Even using a Dynaglide mode, the burr could not be advanced through the Guidezilla because of resistance at the proximal metallic zone of the catheter. At this point, we changed to a Dio catheter (Goodman) with use of the MCT technique in order to deliver the burr. The Dio catheter reached beyond the tortuosity of the vessel easily by using an anchor balloon technique. We placed the burr just distal to the Dio, and performed multiple passes at 200,000 rpm. This allowed sufficient dilation of a non-compliant balloon, leaving no stenosis. Finally, we implanted a drug-eluting stent to achieve TIMI-3 flow. Use of an over-the-wire Dio catheter, along with the MCT technique, allowed for the RA burr to be easily advanced.

Introduction

Stent under-expansion is an important trigger both for in-stent restenosis and stent thrombosis. Good lesion preparation is of crucial importance before stent implantation.¹ Rotational atherectomy (RA) using the Rotablator (Boston Scientific) is useful for debulking the hard calcified matrix and modifying vessel compliance.² However, a main limitation of RA is difficulty in advancing the device towards the distal lesion, particularly in a very tortuous coronary artery. In such cases, there is an increased risk of vessel perforation using RA.³ With respect to delivering a device such as a stent and a balloon, the “mother-and-child” technique (MCT) can be useful in cases where strong backup is needed.⁴ 

The Dio catheter (Goodman), a thrombus aspiration catheter, has been sometimes used in the MCT to deliver a balloon or stent, or perform intravascular ultrasound in a tortuous coronary artery.⁵ In this report, we describe and discuss a case of primary percutaneous coronary intervention (PCI) in which a heavily calcified stenotic lesion at the distal part of a tortuous right coronary artery (RCA) was successfully treated using the Dio catheter to facilitate delivery of the RA burr.  

Case Report

A 70-year-old female with renal failure requiring dialysis, with hypertension and hyperuricemia, was admitted to our emergency room with chest and back pain. Her prescribed medications were candesartan, benidipine, and febuxostat. Blood pressure was 140/88 mmHg. Electrocardiogram (ECG) revealed ST elevation in II, III and aVF leads, and cardiac troponin T was positive. Echocardiogram showed hypokinesis of the inferior left ventricular (LV) wall. According to these findings, the patient was diagnosed with ST-elevation myocardial infarction (STEMI). After administration of aspirin and clopidogrel, she was brought to the cardiac catheterization laboratory for PCI. Initial angiogram using a right femoral access demonstrated a subtotal occlusion with TIMI-2 flow at the distal lesion (Figure 1A) in a significantly tortuous RCA (shepherd’s crook morphology) (Figure 1B). Left coronary angiography showed a normal left anterior descending artery and circumflex coronary artery (Figure 2). Thus, PCI was attempted for the distal RCA. The RCA was engaged with an Ikari Femoral Left 4.0 7 French (Fr) guide catheter (Terumo). With great difficulty, the stenosis was crossed with a floppy wire (Sion Blue, Asahi Intecc) using a Finecross (Terumo) microcatheter. We attempted to deliver a balloon to the distal RCA, but could not reach the lesion because of the proximal tortuosity. Therefore, we barely managed to advance a 2.5 x 15 mm balloon (Hiryu Plus, Terumo) in the target lesion with the MCT with a deep-seated Guidezilla (Boston Scientific). However, repeated balloon dilatation with high pressure could not eliminate the balloon indentation at the lesion due to heavy calcification (Figure 3). Intravascular ultrasound sonography confirmed the near-circumferential calcification. The coronary wire was exchanged for a floppy Rotawire (Boston Scientific) using the microcatheter with guide trapping technique. However, it was difficult to deliver a 1.25 mm RA burr because of the proximal tortuosity (Figure 4). Even though the guidewire was exchanged for an Extra Support Rotawire, the RA burr again failed to advance to the lesion. In order to deliver the RA burr, we used a 6 Fr Guidezilla as a mother-and-child guide extension catheter beyond the tortuosity using an anchor balloon technique. Even though Dynaglide mode was used, the RA burr could not advance through the Guidezilla, because of the resistance at the proximal metallic transition zone of the catheter. We changed to a Dio catheter using the MCT to deliver the RA burr. The Dio catheter was positioned beyond the tortuosity of the vessel easily by use of the balloon anchor technique. The RA burr was placed just distal to the Dio catheter, and we performed multiple passes at 200,000 rpm (Figure 5). This allowed us to sufficiently dilate a non-compliant 3.25 x 15mm balloon (Sapphire II NC, OrbusNeich) without leaving a dilation in the vessel. Finally, we implanted a drug-eluting stent (Xience Alpine, Abbott Vascular) in the lesion, achieving TIMI-3 flow and a good angiographic result (Figure 6).

Discussion

When treating a calcified lesion, the most important aspect is avoiding stent under-expansion, which triggers both in-stent restenosis and stent thrombosis. In this situation, lesion modification with rotational atherectomy is sometimes helpful before stent implantation. The Rotablator facilitated optimal stent implantation and expansion by debulking the hard calcified matrix and modified vessel compliance.² In contrast to plain old balloon angioplasty, this technique removes the obstructive atheroma by means of differential cutting. However, there is an increased risk of several complications, including vessel perforation, especially in a very tortuous coronary artery.³

To facilitate a technically difficult intervention involving a heavily calcified lesion or a very tortuous lesion, many new devices and techniques have been developed, such as buddy wire technique, anchor technique, lower profile stents, and more supportive guiding catheters. Recently, “mother-and-child” technique (MCT), also known as 6-in-5 technique or guide extension catheter, has been used for device delivery in calcified or tortuous lesions that make device deployment difficult. There are two types of catheters used for the MCT: over the wire and rapid exchange. Mamas et al reported the utility of such catheters to deploy a coronary stent for a tortuous lesion and concluded that the use of a rapid-exchange catheter was easier than use of an over-the-wire catheter.^6,7 These catheters have been used to deliver coronary stents and other devices such as an intravascular ultrasound catheter or an RA burr. The GuideLiner (Vascular Solutions), a rapid-exchange guide extension catheter, has been reported to deliver RA burrs in tortuous vessels.^8,9 Ogita et al reported successful PCI with RA in an anomalous RCA using the Dio catheter,¹⁰ concluding that the Dio catheter is more useful for treating an anomalous coronary artery with a RA burr than a rapid-exchange guide extension catheter because of the Dio catheter’s greater backup support, ease in delivering the burr, and safety, allowing the operator to avoid the risk of burr entrapment. In our case, we first used Guidezilla, a rapid-exchange catheter, to deliver a 1.25 mm RA burr. Although a 1.25 mm RA burr can theoretically pass through the 6 Fr Guidezilla, which has a 1.44 mm inner lumen diameter, the burr could not be advanced. We assumed that the RA burr was caught at the proximal metallic transition zone of the Guidezilla, because the catheter was curved in the aortic arch. An over-the-wire Dio catheter was used with the MCT to deliver the RA burr. The Dio catheter is not rapid exchange and has a larger inner lumen size (1.51 mm) (Figure 7) than that of the 6 Fr Guidezilla (1.44 mm). The Dio catheter is composed of inner and outer catheters, and the outer catheter usually advances with the inner catheter (Figure 8), or through the use of an anchor balloon technique with a usual small balloon. In our case, the Dio catheter could advance using an anchor balloon technique. Furthermore, without any resistance, the RA burr could be deployed beyond the tortuous coronary artery.  

In conclusion, the Dio catheter may be a useful device to deploy a burr or a stent in a very tortuous coronary artery, particularly when deployment of an RA burr is unsuccessful despite use of the MCT with a rapid-exchange guide extension catheter. 

References

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Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Yusuke Hosokawa, MD, Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, at y-hosokawa@nms.ac.jp.