Use of a 0.014´´ Guidewire for Cannulation of Left Coronary Ostium with a Difficult Anatomy

Engagement of the left coronary ostium is usually accomplished with the standard Judkins technique in the majority of patients without further manipulation.1 For the minority of patients with difficult anatomies, there is an enormous variety of catheters available with different sizes and unique designs.2–6 However, catheter selection in most labs may be limited to those most frequently used (i.e., Judkins, Amplatz, Multipurpose), resulting in inadequate imaging of the coronary arteries. We report a case with a difficult left coronary anatomy in which the left coronary ostium could not be cannulated with the aforementioned standard techniques and catheters. However, cannulation was eventually successful with the help of a 0.014´´ angioplasty guidewire. Case Report. An 85-year-old female patient was hospitalized with the diagnosis of acute anterior myocardial infarction. She was not given thrombolytic therapy because of her age and was followed with conservative treatment. Her history revealed an attempted angiogram 4 months prior at another center, where left coronary injection failed because of the inability to engage the left coronary ostium despite the use of 6 different catheters including the Judkins, Amplatz and Multipurpose catheters with different sizes and curves. On the 4th day of her hospitalization, we decided to perform an angiogram because of unstable angina despite medical therapy. In the light of the previous angiography report, we first performed a left ventriculogram which revealed a slight apical hypokinesia and right coronary injection with a mild stenosis. The aortic root was normal except for a slight angulation of the ascending aorta. We decided to start with a standard 7 French Judkins 4.0-cm tip left catheter to see the anatomy of the ostium. On this first attempt, we were not able to cannulate because of a downward curve of the ostium (a Shepherd’s Crook anatomical variation) (Figure 1A). The catheter could only be advanced to a point just below the ostium, and forward pushing, clockwise and counterclockwise manipulations did not prove to be helpful. Despite the maneuvers to direct the tip of the catheter vertically, it was not possible to engage the ostium. Considering the previous history of unsuccessful attempts with various catheters with different curves, we decided not to try again, instead using a 0.014´´ extra-support angioplasty guidewire (ACS High Torque Extra Support; Guidant Corporation, Santa Clara, California) over which we might slide the catheter into the coronary artery. We left the catheter in its place just below the ostium and steered the guidewire to the proximal part of the circumflex artery (Figure 1B), over which we carefully advanced the catheter, ending up with successful engagement of the ostium (Figures 1C and 1D). Angiography revealed a severe mid left anterior descending coronary artery lesion with thrombus (Figure 1E). After a bolus dose of tirofiban (0.15 µg/kg/minute), we cannulated the ostium once again with the same method using a 6 French JL 4.0-cm tip guiding catheter and successfully implanted an ACS Tetra 3.5 x 23 mm stent (Guidant Corporation). Discussion. With the production of various unique design catheters suitable for ostial cannulation, nonselective technique has largely been replaced with selective angiography.2–6 Appropriate catheter selection and careful manipulation are essential for the success of the procedure. These measures are especially important in the presence of anomalous origins and difficult anatomies. Although the standard Judkins technique is known to be successful in the majority of patients, those with enlarged aortic root secondary to aortic valve disease or hypertension, peripheral tortuosity and angulated ascending aorta may need extra maneuvers and special catheters for the cannulation of the ostium. In such cases, catheters with larger loops or designs can be used and angiography can be successfully performed. However, infrequently used catheters may not be available at the time of the procedure, and nonselective aortic root injection (although not very helpful) might be the only remaining option to evaluate the coronary anatomy. The use of percutaneous transluminal coronary angioplasty guidewires for selective intubation of the internal mammary arteries was previously reported.7 We present a case with difficult anatomy of the left coronary ostium, in which the standard Judkins, Amplatz, Multipurpose and Sones catheters are not effective. We also used an angioplasty guidewire with good support and steered it into the proximal part of the circumflex artery to provide support for catheter advancement and engagement. Since most catheterization laboratories have a finite variety of catheters that are satisfactory for the majority of cases, a guidewire support could be beneficial in cases where these catheters are not effective, as in our case. However, special attention should be paid during advancement of the guidewire to minimize the associated risks, such as dissection.

1. Judkins MP. Selective coronary arteriography: A percutaneous transfemoral technique. Radiology 1967;89:815. 2. Amplatz K, Formanek G, Stanger P, et al. Mechanics of selective coronary artery catheterization via femoral approach. Radiology 1967;89:1040. 3. Brown RIG, MacDonald AC. Use of 5 French catheters for cardiac catheterization and coronary angiography: A critical review. Cathet Cardiovasc Diagn 1987;13:214–217. 4. Johnson LW, Lozner EC, Johnson S, et al. Coronary angiography 1984–1987: A report of the registry of the Society for Cardiac Angiography and Interventions. I. Results and complications. Cathet Cardiovasc Diagn 1989;17:5. 5. Kohli RS, Vetrovec GW, Lewis SA, et al. Study of the performance of 5 French and 7 French catheters in coronary angiography: A functional comparison. Cathet Cardiovasc Diagn 1989;18:131. 6. O’Sullivan JJ, McDonald K, Crean PA, et al. Cardiac catheterization with 5 French catheters. Br Heart J 1990;64:211–213. 7. Kuntz RE, Baim DS. Internal mammary angiography: A review of technical issues and newer methods. Cathet Cardiovasc Diagn 1990;20:10–16.