Injecting Lubricant into the Guiding Catheter Enables Stent Deployment

The majority of percutaneous coronary and renal artery interventional failures is due to the inability to deploy stents in patients with tortuous arteries, fibrotic lesions and/or calcified plaque. Approximately 3% of all interventional procedures are not successful despite current stent design and deployment techniques.¹ An earlier report on RotaGlide™ (Boston Scientific Corporation, Natick, Massachusetts) facilitated stent delivery in two cases has described the use of either dipping the stent into the undiluted lubricant or applying the lubricant to the surface of the stent with a syringe prior to inserting the stent into the guiding catheter.² This report demonstrates that injecting 2 cc of undiluted RotaGlide into the guiding catheter, when the stent is proximal to the lesion site in the artery, can facilitate stent delivery into patients Case Reports Patient 1. A 57-year-old Caucasian male who presented with Class III angina, along with a stress test exhibiting anterior inducible ischemia, underwent cardiac catheterization. The coronary angiogram demonstrated a highly angulated mid-left anterior descending coronary artery (LAD) stenosis (Figure 1). The left main artery was engaged with a 6 Fr EBU 3.75 guiding catheter (Guidant Corporation, Indianapolis, Indiana) and a Medtronic-AVE silk wire (Medtronic, Inc., Minneapolis, Minnesota) was used to wire the LAD. The stent could not be advanced to the lesion site despite predilatation that was performed using a 3.0 x 15 mm Maverick™ balloon (Boston Scientific Corporation, Natick, Massachusetts). Further attempts to deliver the stent were unsuccessful despite the use of a Mailman buddy wire (Boston Scientific) (Figure 2). A 3.0 x 16 mm Taxus® (Boston Scientific) stent was advanced just proximal to the lesion site on the Mailman wire. A 2 cc dose of undiluted Rotaglide was administered into the guiding catheter using a 2 cc syringe. The 3.0 x 16 mm Taxus stent was then delivered without difficulty to the lesion site in the mid LAD. The silk wire was removed and the stent was deployed at 14 atmospheres. There was some plaque shifting just proximal to the initial stent, and this was covered with a 3.0 x 8 mm Taxus® stent. The CPK and troponin levels after the lubricant and stenting procedure were within normal limits. The patient’s TIMI 3 flow was normal pre- and postprocedure. A satisfactory result was revealed on the final angiogram (Figure 3). Patient 2. A 60-year-old Caucasian female with uncontrolled hypertension and a high-grade right renal artery stenosis underwent intervention (Figure 4). The right renal artery was engaged with a 7 Fr RES guiding catheter (Boston Scientific). The right renal artery was wired with a 0.014 inch S’port™ wire (Guidant Corporation, Indianapolis, Indiana). A 7.0 x 18 mm Express® biliary stent (Boston Scientific) was unsuccessfully delivered in the right renal artery due to a fibrotic lesion (Figure 5). Aggressive pushing of the stent produced guiding catheter dislodgement. However, the guidewire remained in place. Due to the risk of distal renal artery perforation, a buddy wire technique was not employed. At this point, with the stent proximal to the lesion, 2 cc of Rotaglide was injected into the guiding catheter. The stent was delivered with ease (Figure 6). There was no creatinine rise postprocedure, and renal function after the stent placement was normal. Discussion This is the first report of Rotaglide injection into a guiding catheter to deliver stents successfully in patients who have failed standard stent delivery methods. Injecting Rotaglide into the guiding catheter with the stent just proximal to the lesion site allows a higher concentration of lubricant to assist the stent delivery. In patient 1, a larger amount of lubricant, as well as its application, may have resulted in decreased friction of the buddy wire and the stent. Additionally, the lubricant amount may have also decreased the friction between the stent and the disease in the coronary artery. The prior report did not involve the use of a buddy wire along with lubricant-facilitated stent delivery.² Given the extremely angulated lesion site, use of the rotational atherectomy device did not appear feasible. This is also the first article on Rotaglide injection into a guiding catheter in order to deliver a renal stent, as demonstrated in patient 2. Renal stenting has been associated with stent dislodgement.^3,4 The distal renal arteries have a higher rate of guidewire perforation.⁵ This fact makes wires larger than 0.014 inch and buddy wires unattractive. In patient 2, delivering the lubricant through the guiding catheter was expedient, fluoroscopic time was minimal and positive results were achieved. Therefore, lubricant-facilitated stent delivery is also advantageous for renal arteries. Overall, these two procedures involving coronary and renal arteries demonstrate that the technique of injecting Rotaglide into the guiding catheter enables stent deployment when other standard techniques are unsuccessful. Rotaglide lubricant is an emulsion composed of olive oil, egg yolk, phospholipids and glycerin. The pH range is 8.0 to 9.0. The only relative contraindication is in patients with known allergies to eggs. Other potential contraindications would include existing allergies to the additional ingredients of olive oil, glycerin and so forth. The product has been approved for use in reducing friction in rotational atherectomy and has been widely used for this procedure with no reported cases of anaphylaxis. Unpublished data related to FDA (U.S. Food and Drug Administration) approval of the Rotablator® rotational atherectomy system (Boston Scientific) showed no adverse effect of the lubricant on platelet aggregation when exposed to freshly drawn, heparinized human blood.⁷ There are no known dose limitations for this technique. However, the pH of 8.0 is a slightly higher pH than other contrast agents such as iodixanol and iomexol, which have a pH range of 6.8 to 7.7. Therefore, we use only 2 cc of the lubricant when injecting directly into the vessel. We have experienced no allergic, anaphylactic or arrhythimic effects with its use. Lubricant-facilitated stent delivery is safe, inexpensive and convenient. Based on the aforementioned positive results, lubricant-facilitated stenting may be the best option when conventional techniques have failed.

1. Mukerjee D, Wainess RM, Dimick JB, et al. Variation in outcomes after percutaneous coronary intervention in the United States and predictors of periprocedural mortality. Cardiology 2005;103:143–147. 2. Chan AW, Ramee SR, Collin T, et al. Rotaglide-facilitated stent delivery: Mission accomplished. Catheter Cardiovasc Interv 2003;59:477–487. 3. Nolan BW, Schermerhorn ML, Rowell E, et al. Outcomes of renal artery angioplasty and stenting using low-profile systems. J Vasc Surg 2005;41:46–52. 4. Ivanovic V, McKusick MA, Johnson CM 3rd, et al. Renal artery stent placement: Complications at a single tertiary care center. J Vasc Interv Radiol 2003;14(2 Pt 1):217–225. 5. Axelrod DJ, Freeman H, Pukin L, et al. Guide wire perforation leading to fatal perirenal hemorrhage from transcortical collaterals after renal artery stent placement. J Vasc Interv Radiol 2004;15:985–987. 6. Bush RI, Najibi S, MacDonald MJ, et al. Endovascular revascularization of renal artery stenosis: Technical and clinical results. J Vasc Surg 2001; 33:1041–1049. 7. FDA Approval: 510(k) Reference No. K993648. Peripheral Rotablator® Rotational Angioplasty System with the RotaLink™ Exhangeable Catheter. Division of Cardiovascular, Respiratory, and Neurological Devices, Department of Health and Human Services. Nov. 24, 1999.