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Enhancing Back-up Support During Difficult Coronary Stent Delivery: Single Center Case Series of Experience with the Heartrail II Catheter
Editor’s Note: “This case describes the use of a novel support catheter in tortuous cases providing extra back-up support with minimum trauma. Clearly Heartrail II catheters like the Guideliner should be reserved for difficult cases. Other techniques which can be tried in tortuous cases, are the use of 'buddywire' and advancing the stents on a less stiff wire and withdrawing the side buddy wire before stent deployment." — Samin K. Sharma, MD, Mount Sinai Medical Center, New York, New York
Despite continued advances in creating lower profile intra-coronary balloons and stents, technical difficulties with stent deliverability are frequently encountered. Failure rates for percutaneous coronary intervention with stenting have been reported to range from 2.7–3.3%, with inability to deliver the stent to the desired location being the predominant reason.1,2 Continued advances in guide catheters, wires, and device flexibility have reduced this failure rate by more than half over the past twelve years.3 However a multitude of reasons may still impact on successful stent delivery including hostile guide catheter anatomy, excessive artery tortuosity and lesion calcification. Recent advances in catheter design have yielded soft ended atraumatic catheters for use within standard guide catheters — the so called “double coaxial” guiding catheter technique. These catheters have been designed to facilitate intra-arterial device deliverability. We report our preliminary experience using the 5 Fr Terumo guide catheter (Heartrail II, Terumo, Somerset, New Jersey) from a single center.
Case Reports. Initial inability to successfully deliver a device (balloon or stent) despite perceived optimal guide and wire choice (including standard techniques such as use of a ‘buddy wire) by an experienced operator provoked employment of the Heartrail II 
catheter. This catheter was used in six cases outlined in Table 1. Three of the patients underwent primary percutaneous coronary intervention (PCI) for ST-segment elevation MI (STEMI) (Figure 2), two for Non-STEMI and one patient for unstable angina (Figure 1). The mean patient age was 72.5 ± 5.4 years and all had type C lesions. The mean number of stents deployed was 3.17 ± 2.39, with a mean procedure X-ray screening duration of 35.04 ± 7.79 minutes. No complications relating to ostial artery catheter-induced dissections were encountered.
Figure 1 demonstrates the right coronary angiographic findings in a 65-year-old male 
who presented with progressive angina (Canadian Cardiovascular Society classification 2) of 4 weeks duration. Angiography of the left coronary artery system did not show any high-grade stenosis. Prior nuclear exercise stress testing had suggested reversible inferior myocardial wall ischemia. Following anti-coagulation with intravenous heparin, a 6 Fr Amplatz right guide was used to selectively engage the RCA (Figure 1A). Despite deep engagement of the guide and the advancement of a buddy wire to the distal right coronary artery (RCA), we were unable to position a 2.5 x 12 mm Maverick (Boston Scientific, Natick, Massachusetts) across the distal stenosis in the mid RCA. Under fluoroscopy we proceeded to advance the Heartrail II catheter just proximal to the stenosis (Figure 1B). Following successful balloon angioplasty we then delivered a 3.0 x 23 mm drug-eluting stent (Xience V, Abbott Vascular, Santa Clara, California) to the lesion and successfully deployed it with balloon inflation to 14 atm for 30 seconds (Figure 1C).
In Case 3 (Figure 2), an 89-year-old female presented with acute onset central chest 
pain of three hours duration. Electrocardiography revealed an acute inferior STEMI. She was treated with intravenous heparin and dual antiplatelet therapy in the emergency department. Diagnostic angiography demonstrated a thrombotic occlusion of her mid RCA. An intracoronary bolus of abciximab was administered following selective engagement with a 6 Fr Hockey Stick guide (HS1, Mach 1, Boston Scientific, Natick, Massachusetts) and wire advancement to the posterior descending artery. After pre-dilation of the lesion with a 2.5 x 15 mm Maverick balloon (Boston Scientific), an attempt to deliver a 2.75 x 18 mm Xience stent failed despite double wiring the vessel. We then performed deep engagement of the RCA with the HeartRail II catheter which enabled the stent to be delivered and successfully deployed (Figure 2C). A 3.0 x 12 mm Xience stent was then deployed in the proximal RCA following retraction of the HeartRail II catheter without difficulty.
Discussion. We describe our experience using the Heartrail II catheter. This is a 120 cm 5-Fr soft straight-tipped catheter which is delivered within a standard 6 Fr coronary guide catheter. Up to 13 cm of this 5 Fr catheter may extend beyond the coronary guide, allowing deep engagement of the target coronary artery in an atraumatic fashion. This facilitates delivery of intracoronary devices especially stents, and is particularly useful where tortuous coronary anatomy exists. Prior work has demonstrated this catheter’s ability to increase back-up support especially relevant in cases of PCI of the right coronary artery.4,5 Furthermore, it enhances stent delivery by reducing the frictional forces encountered within calcified and diseased arteries.6
While our initial experience with the Heartrail II catheter was positive, some difficulties were encountered. The initial set up can take more time and sub-optimal opacification of the coronary artery can occur. This highlights the importance of compiling detailed angiograms prior to proceeding with this device to comprehensively delineate the target lesion(s). The operator must be aware of possible anatomical distortion of the artery with delivery of the 5 Fr catheter, similar to the effect seen with stiff guidewires. Another danger is the risk of air entrainment leading to air embolism and careful back bleeding is mandatory before injection. Finally particular care is required when advancing the Heartrail to avoid inducing a dissection.
Conclusion. The Heartrail II guide catheter is a useful device to overcome current shortcomings experienced during stenting of complex lesions where high friction forces prohibit successful PCI outcomes with conventional techniques. Despite having a relatively high cost it represents a useful addition to the interventionalist’s armamentarium.
References
- Lohavanichbutr K, Webb JG, Carere RG, et al. Mechanisms, management, and outcome of failure of delivery of coronary stents. Am J Cardiol 1999;83:779–781, A9.
- Nikolsky E, Gruberg L, Pechersky S, et al. Stent deployment failure: Reasons, implications, and short- and long-term outcomes. Catheter Cardiovasc Interv 2003;59:324–328.
- Cantor WJ, Lazzam C, Cohen EA, et al. Failed coronary stent deployment. Am Heart J 1998;136:1088–1095.
- Mamas MA, Fath-Ordoubadi F, Fraser D. Successful use of the Heartrail III catheter as a stent delivery catheter following failure of conventional techniques. Catheter Cardiovasc Interv 2008;71:358–363.
- Takahashi S, Saito S, Tanaka S, et al. New method to increase a backup support of a 6 French guiding coronary catheter. Catheter Cardiovasc Interv 2004;63:452–456.
- Nakamura M, Shiba M, Wada M. A novel method for deploying a stent into a highly angulated position through use of a stent strut: Application of a five-in-seven system. J Invasive Cardiol 2006;18:E105–E107.
