A New Technique for Coronary Guide Catheter Exchange Over Coronary Guidewire Using GuideLiner Catheter

ABSTRACT: Guide catheter exchange over coronary guidewire can be challenging, yet is necessary in certain clinical scenarios. At the same time, maintaining coronary guidewire position across a predilated lesion is important to prevent vessel lumen closure. We present a technique of guide catheter exchange over a coronary guidewire with GuideLiner support. 

J INVASIVE CARDIOL 2014;26(5):E56-E58

 Key words: GuideLiner catheter, guide catheter exchange

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Maintenance of coronary guidewire position across a lesion is important during percutaneous coronary intervention (PCI), as abrupt closure of the vessel lumen can occur after balloon dilation of a coronary lesion. In this setting, loss of coronary guidewire position in the vessel lumen can significantly alter the outcome of the procedure. Guide catheter exchanges become necessary in certain clinical scenarios.

Upsizing to deliver bulky equipment or a need for a different guide catheter curve for better support are some of the situations when exchanges are required. Guide catheter exchanges over coronary guidewires can be difficult for a number of reasons. Commonly used catheter exchange wires have a larger diameter as compared to coronary guidewires (0.035 inches vs 0.014 inches), thus placing them in coronaries is generally not a good option. Coronary guidewires are usually not supportive enough to safely complete a guide catheter exchange with preservation of the coronary guidewire position. Problems arise mostly in repositioning the catheter in the coronary ostium over a coronary guidewire. Commonly used exchange wires tend to straighten catheters as they advance into the vasculature. The catheter assumes its normal curvature only after the wire is retracted. Coronary guidewires, due to their softer nature, tend to straighten the catheter to a lesser extent. Thus, the catheter advances into the vasculature with its curvature only partially straightened. As the catheter advances retrograde into the ascending aorta, it tends to pull the guidewire out of the coronary artery.

We present a technique of guide catheter exchange over a coronary guidewire with GuideLiner (GL) catheter support that alleviates the problem of caliber mismatch that often results in loss of guidewire position.

Case Report #1. An 88-year-old male presented for an elective PCI of 90% mid-left anterior descending (LAD) coronary artery stenosis (Figure 1A). A 6 Fr Judkins Left 4.0 (JL4) guide catheter was initially used via right femoral artery access with a Balance MiddleWeight (BMW) universal guidewire (Abbott Vascular). In spite of multiple balloon dilations of the lesion and GL support, the stent could not be advanced to the LAD stenotic area. Thus, a decision was made to exchange the current guide catheter for a 6 Fr Extra Back-up (EBU) 4.0 catheter for extra support. A Doc Guidewire Extension (Abbott Vascular) was connected to the BMW and under fluoroscopic guidance, the JL catheter was slowly retracted and removed. The distal tip position of the BMW was maintained. The EBU was advanced over the wire into the descending thoracic aorta. Next, the GL was advanced into the EBU over the BMW with its distal several centimeters protruding out into the aorta, creating a telescopic system (Figure 1B). The guide catheter was then advanced with the BMW in fixed position, and the GL moved to the left main coronary ostium (Figure 1C). The EBU was then advanced over the GL to the ostium (Figure 1D), with the system providing good enough support to complete the procedure successfully (Figure 1E).

Case Report #2. A 50-year-old male underwent elective PCI of the right coronary artery (RCA) (Figure 1F). A 6 Fr Judkins Right 4.0 (JR) guide catheter was used via right femoral approach. A BMW wire was advanced into the distal RCA. The GL was advanced into the guide catheter to provide extra support for stent delivery. In spite of multiple balloon predilations and GL support, a stent could not be delivered to the lesion. Thus, as a more supportive guide catheter was needed, we exchanged the guide for a 6 Fr Amplatz left 0.75 catheter using the technique described above (Figures 1G and 1H). With the new supportive system, the procedure was completed without difficulty and with good final result (Figure 1I).

Discussion. Interventional cardiologists sometimes come across cases where exchange of the guide catheter is required over a coronary guidewire, without losing the guidewire distal tip position. Often enough, as in our cases described above, a more supportive guide catheter is required for delivering equipment to the coronary lesion. In such cases, maintenance of coronary guidewire position across the lesion is important. The GL is a single-lumen, 145 cm device, with the distal 20 cm catheter and the rest comprising a stainless-steel shaft.

The distal part is soft, flexible and straight.¹ The GL is utilized frequently as a mother and child system where deep intubation of a coronary artery is performed for extra support. Recently, we demonstrated the use of this device as a thrombectomy catheter.² In the above case, we describe yet another application of this versatile catheter. With the telescopic system, coronary cannulation is performed with the GL over a guidewire. As it is a soft and straight catheter, the chance of coronary guidewire retraction is decreased. The guide catheter is then advanced over the GL and guidewire quite safely to the coronary ostium.

Other guide catheter exchange techniques have been described. One technique uses a 0.035 inch exchange wire which is advanced to the aortic valve cusp and the guide catheter is exchanged over this wire as well as the coronary guidewire, left in PCI position. In another technique, a balloon catheter over the coronary guidewire is used during retraction and advancement of the guide catheter to provide extra support.³ In our technique, the balloon shaft can also be used as the third piece of the telescopic system (grandmother-mother-child telescopic system) with the GL for even more effective and safe guide catheter exchanges.

Conclusion. Guide catheter exchange over coronary guidewire with GuideLiner support is a safe and effective technique. It gives comfort of maintaining coronary guidewire position in complex PCI.

References

1. GuideLiner catheter instructions for use. Available at https://vasc.com/wp-content/uploads/2013/07/GuideLiner-Catheter-IFU-US-42-0776-01-rH.pdf.
2. Stys AT, Stys TP, Rajpurohit N, Khan MA. A novel application of GuideLiner catheter for thrombectomy in acute myocardial infarction: a case series. J Invasive Cardiol. 2013;25(11):620-624.
3.  Selig MB, Yazdanfar S. Guide catheter exchange techniques: bi-coaxial and other methods. Cathet Cardiovasc Diagn. 1997;41(4):442-444.

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From the University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted September 3, 2013 and accepted September 4, 2013.

Address for correspondence: Muhammad Ali Khan, MD, 1301 W. 18th street, Sioux Falls, SD, 57105. Email: Muhammad.khan@sanfordhealth.org