PercuSurge Guiding Catheter Thrombectomy: A New Thought On an Old “Poor-Man’s” Technique

Dear Editor,

The recent article by Yoshimachi et al, entitled A Novel Method of PercuSurge Distal Protection in a Five French Guiding Catheter without an Export Aspiration Catheter1 is interesting as well as important, and deserves some comments and critiques. The degree of microvascular plugging/unplugging and distal perfusion determine postprocedure prognosis and myocardial function. Up to 25% of patients with successful epicardial vessel recanalization during acute myocardial infarction have distal embolization and reduced or absent distal tissue perfusion.

Distal coronary embolization occurs mainly during saphenous vein graft (SVG) percutaneous intervention (PCI), native coronary PCI, especially in a heavy thrombus-containing lesions during acute myocardial infarction (AMI),2  as well as with valunerable plaque PCI.3,4 Although glycoprotein (GP) IIb/IIIa inhibitors have contributed to an improved success rate during native vessel PCI, treating large clot burden lesions in SVGs or native vessels still carries a high risk for distal thromboembolization.5

Several techniques and devices have been developed in recent years to protect against distal embolization, preserve myocardial function and improve procedural outcomes and prognosis mainly through: 1) thrombectomy devices for aspiration thrombectomy, fragmentation thrombectomy, rheolytic thrombectomy...etc., and 2) distal protection devices (DPD) for distal filtration, distal occlusion and proximal occlusion. The temporary occlusion-aspiration system (GuardWire or PercuSurge) consists of a guidewire with a central inflation lumen and an elastomeric balloon with a 2.8 Fr crossing profile.

Diluted contrast injection causes balloon inflation (2.5–5.0 mm or 3.0–6.0 mm diameter), preventing anterograde flow. Intervention is performed over the wire, and coronary thrombus or liberated debris trapped proximal to the balloon is aspirated through a 5 Fr monorail Export aspiration catheter (7 Fr guiding catheter compatible). The occlusion balloon is then deflated and flow is restored. The duration of GuardWire balloon inflation varies with different procedural characteristics and operator experience. In one study, for example, the mean occlusion time was 5.4 minutes.6 A small study using the GuardWire during primary PCI in patients with angiographic high-burden thrombus showed improved flow and myocardial blush grade (MBG), but this did not translate into a reduction in 30-day major adverse cardiac events (MACE).7 In the large randomized EMERALD study in patients with AMI, the GuardWire markedly reduced the incidence of angiographic slow or no-reflow, but there was no significant overall effect on ST-segment resolution or infarct size. Napodano et al showed that in AMI with angiographic evidence of thrombus, using thrombectomy devices significantly improved pre-PCI flow, post-PCI MBG and ST-segment resolution; again, this was not translated into hard clinical endpoints, and there was a 9% failure rate to cross the lesion.8 Overall, there are no data to suggest that the routine use of DPD or thrombectomy devices is beneficial in ACS-PCI, although it may be difficult to show the benefits of protection against embolization that undoubtedly happen during AMI-PCI.

SVG-PCI carries a high risk of MACE, mainly no-reflow and AMI.9 The pathophysiologic and histologic nature of coronary thrombi and distal embolization is different between SVGs (mainly cholesterol-rich emboli and necrotic core debris)10 and native vessels (mainly platelet-rich emboli),11 and this difference probably explains why the protection offered by GP IIb/IIIa inhibitors during native vessel PCI has not been mirrored in SVG interventions.12,13 Also, the integrity of the endogenous thrombolytic response is important in the spontaneous lysis of platelet thromboemboli in the distal bed.

Yoshimachi et al, in their report on PercuSurge distal protection using a 5 Fr guiding catheter for aspiration, remind us of the good-old days prior to the availability of the current thrombectomy devices when we used to deep-seat a diagnostic catheter inside the treated vessel through a guiding catheter (“child-in-mother” technique) to aspirate coronary thrombus. This method is still used in desperate situations whenever thrombectomy devices are not available, hence, its current name, “the poor-man’s thrombectomy technique”.

In this retrospective, nonrandomized report, Yoshimachi et al used a single 5 Fr guiding catheter and utilized a new de Percu method instead of the Export aspiration catheter during AMI-PCI in 14 patients and compared the results to 18 control patients treated with the conventional PercuSurge system. Although this method is intriguing, with the advantage of using a small sheath size, less occlusion time, fluoroscopy time and cost, some of the shortcomings (limitations) of this method we think worth mentioning are: difficulty in deep-seating the guiding catheter (even if 5 Fr) in calcific, tortuous, small vessels, eccentric, and firm lesions, as well as in distal lesions, and hard atrioventricular groove locations. Coronary spasm, pressure dumping, and reduced or no-flow to the proximal branches during guiding catheter deep-intubation are of concern as well, especially in patients with severe left ventricular impairment.

Thus, although this is a new de Percu method, we have to individualize cases according to vessel, lesion characteristics, thrombus burden and, until we have a large-scale, prospective, randomized trial to validate current findings, we should be very selective in utilizing this method.

Sincerely,

Walid Hassan, MD, FSCAI, FACC, FACP, FCCP, FAHA
and Hani Al Sergani, MD
King Faisal Heart Institute, MBC 16
King Faisal Specialist Hospital and Research Center
P.O. Box 3354, Riyadh 11211, Kingdom of Saudi Arabia
E-mail:  hassan_walid@hotmail.com
 

J INVASIVE CARDIOL 2008;20: 526-527