Challenges Associated With Use of the GuideLiner Catheter in Percutaneous Coronary Interventions

Abstract: The GuideLiner catheter is an easy-to-use guide catheter extension that can facilitate vessel engagement and equipment delivery. We present two cases that illustrate two potential challenges associated with use of the GuideLiner catheter: (1) stent loss and deformation during attempts to advance it through the GuideLiner catheter collar; and (2) displacement of the GuideLiner catheter distal marker into a coronary artery. Awareness of these potential complications may render safer the use of this valuable interventional tool.

J INVASIVE CARDIOL 2012;24(7):370-371

Key words: GuideLiner catheter, complications

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The GuideLiner catheter (Vascular Solutions) can significantly facilitate vessel engagement and equipment delivery during challenging percutaneous coronary interventions (PCI),^1-6 but may also carry risk for device-specific complications.^2,7 We present two cases that illustrate potential challenges associated with use of the GuideLiner catheter during PCI.

Case 1

In the first case, a stent was stripped off its delivery balloon and became deformed while attempting to advance it from the guide lumen into the GuideLiner lumen (Figure 1). A 6 Fr AL¹ guide catheter and a 6 Fr GuideLiner were used. The GuideLiner catheter was removed together with the deformed stent without any complications.

Case 2

A 64-year-old man was referred for percutaneous coronary intervention of a diffusely diseased and heavily calcified left anterior descending artery (Figure 2A). Both the circumflex and the right coronary artery (Figure 2B) had complete occlusions. Left ventricular ejection fraction was 20%.

Due to the high risk of PCI on the left remaining vessel in a patient with markedly decreased left ventricular systolic function, a Tandem Heart assist device (Cardiac Assist) was inserted prior to the intervention. Anticoagulation was achieved with unfractionated heparin. The left main was engaged with an 8 Fr XB 3.5 guide catheter that provided excellent support. Balloon and stent delivery was difficult due to calcification and was achieved using multiple techniques, such as multiple buddy wires, insertion of an Ironman wire (Abbott Vascular), insertion of an 8 Fr GuideLiner catheter (Figure 2C) and use of the distal anchoring technique (Figure 2D).

During the stent delivery attempts, the GuideLiner distal marker was displaced into the mid left anterior descending artery (Figure 2E). A coronary stent was deployed inside the GuideLiner marker, trapping it between the stent and the coronary artery wall, maintaining normal antegrade flow (Figures 2F and 2G). An excellent final angiographic result was achieved (Figure 2H) with an uneventful patient recovery. 

Discussion

Our cases highlight two potential complications associated with use of the GuideLiner catheter: dislodgement of a stent during attempts to advance it through the GuideLiner metal “collar” and dislodgement of the GuideLiner distal marker.

The GuideLiner is a guide catheter extension that can significantly facilitate vessel engagement and equipment delivery in complex native coronary and saphenous vein graft interventions.^1-4 The GuideLiner catheter consists of a 20 cm distal cylinder that is attached to a push rod. A stainless steel “collar” is located at the transition zone between the cylinder and the push rod. A radiopaque marker is located 2.67 mm from the tip (Figure 2I).

Complications related to use of the GuideLiner catheter have been reported, such as dissection of the target vessel during engagement.² Murphy and Spence recently published a case in which retraction of the metal transition zone “collar” of the GuideLiner catheter caused deformation and tear of a stent balloon.⁷ This complication is similar to what happened in the first case of our series, in which trying to advance a stent through the GuideLiner collar led to stent loss and deformation. Difficulty advancing equipment through the GuideLiner collar is more likely to occur when using guide catheters with a secondary bend, such as an Amplatz guide (Figure 1). To prevent this complication, Murphy and Spence recently proposed “lengthening the silicon-coated straight guide extension beyond its existing 20 cm, to 30 cm, which would result in the interface between the stent balloon and GuideLiner ‘collar’ to be further from the distal aspect of the guide, and more likely to be coaxial within the guiding catheter. This simple modification to the existing GuideLiner model could prevent deformation and/or damage to the balloon stent during retraction of the GuideLiner.”⁷

In the second case, damage of the structural integrity of the GuideLiner catheter occurred when extensive manipulations were required. This led to dislodgement of the distal marker, possibly due to damage of the GuideLiner inner lining from a deformed stent (Figure 2). In both cases, the GuideLiner dysfunction was successfully managed percutaneously without any harm to the patient. Dehiscence of the distal radiopaque ring has been reported with guide catheters. Chen et al8 described a case of embolization of a dehisced radiopaque ring into the proximal circumflex. They inserted a 2.5 mm balloon through the ring, inflated and removed the balloon, retrieving the lost ring. Nanjappa et al⁹ used the same small balloon technique to retrieve the dehisced distal tip of a diagnostic catheter (Judkins left 3.5 diagnostic; Cordis Corporation). In our case, we elected not to attempt retrieval, but instead deployed a stent inside the ring, fully deploying it (Figure 2).

Although several techniques can be used for facilitating complex PCI,^10-12 the GuideLiner is an easy-to-use and readily available tool. Awareness of the above system limitations can simplify and render safer the use of the GuideLiner catheter.

Acknowledgment. We are grateful to Ms. Nancy Gray from the Medical Media department of VA North Texas Healthcare System for her expert assistance with the images. 

References

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12. Mahmood A, Banerjee S, Brilakis ES. Applications of the distal anchoring technique in coronary and peripheral interventions. J Invasive Cardiol. 2011;23(7):291-294.

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From the VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Michael reports support from a Cardiovascular Training Grant from the National Institutes of Health (Award Number T32HL007360). Dr Brilakis reports speaker honoraria from St Jude Medical and Terumo; research support from Abbott Vascular and Infraredx; and salary from Medtronic (spouse). Dr. Papayannis has no disclosures. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted December 28, 2011, provisional acceptance given January 18, 2012, final version accepted February 27, 2012.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. Email: esbrilakis@yahoo.com