A Novel Use of the GuideLiner Catheter in Diagnostic Coronary Angiography

This article received a double-blind review from members of the Cath Lab Digest editorial board.

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

Dr. Balmer-Swain can be contacted at mallorybs@gmail.com.

Case report

A 50-year-old man with a history of gastroesophageal reflux disease, tobacco abuse, and family history of coronary artery disease presented to our office with a complaint of chest discomfort. He had a five-week history of substernal, burning chest discomfort, dyspnea on exertion, and lower extremity edema. Physical exam demonstrated a thin, Caucasian male with normal pulses, jugular venous distension, a II/VI holosystolic murmur at the apex, a III/VI early diastolic murmur, an inferiorly displaced point of maximum impulse (PMI), and pitting edema of both lower extremities. An electrocardiogram revealed non-specific findings. An echocardiogram demonstrated a severely dilated left ventricle with left ventricular (LV) ejection fraction of 16%, a dilated right ventricle, biatrial enlargement, moderate-severe aortic and mitral insufficiency, moderate tricuspid insufficiency, and a dilated aortic root of 7.4cm. A nuclear stress test showed multiple reversible defects and severely depressed LV function. Given non-invasive findings, the patient was brought to the cardiac catheterization lab for left heart catheterization and angiography of the ascending aorta. 

Aortic angiography revealed a severely dilated ascending aorta measuring 7.8cm in diameter with severe aortic insufficiency (Figure 1). Diagnostic angiography of the right coronary artery was uneventful. However, multiple attempts to selectively engage the left main coronary artery (LMCA) were unsuccessful due to the large thoracic aneurysm. Catheters used included, but were not limited to, a 6 French Judkins Left 5, a 6 French Judkins Left 6 (JL6), an Amplatz Left 3, a multipurpose, and multiple extra back-up catheters. Finally, using a 6 French Launcher MB2 guide catheter (Medtronic) with the GuideLiner catheter (Vascular Solutions), we were able to selectively engage the LMCA. The guide catheter was used to aim toward the left coronary ostium, but fell short by several inches. The GuideLiner catheter was then inserted and telescopically advanced to selectively engage the LMCA. There was no dampening of the pressure tracing noted, and angiography was performed without complication (Figure 2). Coronary angiograms revealed critical stenosis of the left anterior descending, left circumflex, and right coronary arteries. The patient subsequently underwent successful coronary artery bypass grafting with aortic root replacement, and repair of his aortic and mitral valves. At his most recent follow-up, his LV function had improved significantly.

Discussion

The GuideLiner catheter is a 20cm extension that is placed through a guiding catheter in a “mother and child” configuration, allowing deep intubation of the target vessel.¹ The GuideLiner catheter was designed to provide increased support to facilitate percutaneous coronary interventions in difficult situations such as distal lesions, chronic total occlusions, and unusual anatomy.² There are also reports of the GuideLiner catheter being used to facilitate aspiration thrombectomy.^3,4 To our knowledge, there have been no reports of using the GuideLiner catheter for diagnostic coronary angiography.

In the case above, the patient tolerated the procedure well and there were no complications. It must be noted, however, that this use of the GuideLiner catheter is off-label and must be used with caution. Other options exist for attempting to image the coronary arteries in the setting of a large ascending aortic aneurysm. One such option would be to use a long, 90cm sheath. This provides extra support to the catheter, preserving a more acute angle around the aortic arch, thereby allowing engagement of the LMCA without requiring support from the aneurysmal aortic wall. In this case, a long sheath was not ideal due to desire to avoid sheath exchange and to decrease the risk of dissection. A second option in this case would be to attempt manual reshaping of a diagnostic catheter such as the JL6. Performing computed tomographic angiography (CTA) of the chest is a third option for imaging the coronary arteries in this situation. However, given that CTA is subject to image degradation due to factors such as heart rate, patient motion, and respiratory motion, it was felt that CTA would not delineate the coronary anatomy well enough in this patient in whom surgical repair of his large aneurysm would be needed. 

Conclusion

Aneurysmal dilatation of the ascending aorta often presents a challenge in diagnostic coronary angiography. While methods exist that allow imaging of the coronary arteries in the setting of large ascending aortic aneurysms, these methods are not sufficient in all patients. We present here a novel method for selective engagement of coronary arteries in patients with large ascending aortic aneurysms using the GuideLiner catheter. We expect that this technique will be useful to many angiographers, and propose that further studies on this use of the GuideLiner catheter are indicated. n

References

1. Kumar S, Gorog DA, Sacco GG, DiMario C, Kukreja N. The GuideLiner “child” catheter for percutaneous coronary intervention - early clinical experience. J Invasive Cardiol. 2010; 22(10): 495-498.

2. Pershad A, Sein V, Laufer N. GuideLiner catheter facilitated PCI--a novel device with multiple applications. J Invasive Cardiol. 2011; 23(11): E254-E259.

3. Parikh A, Ali F. Novel use of GuideLiner catheter to perform aspiration thrombectomy in a saphenous vein graft. Cath Lab Digest. 2013; 21(10). Available online at https://www.cathlabdigest.com/articles/Novel-Use-GuideLiner-Catheter-Perform-Aspiration-Thrombectomy-Saphenous-Vein-Graft. Accessed July 21, 2015.

4. Mani AJ. Novel use of a guide extension mother-and-child catheter for adjunctive thrombectomy during percutaneous coronary intervention for acute coronary syndromes. J Invasive Cardiol. 2014; 26(6): 249-254.