Dual Guide Catheter Technique for Treating Native Coronary Artery Lesions (Full Title Below)

Dual Guide Catheter Technique for Treating Native Coronary Artery Lesions Through Tortuous Internal Mammary Grafts: Separating Equipment Delivery from Target Lesion Visualization

ABSTRACT:Attempts to wire and stent a native coronary artery lesion through a tortuous internal mammary graft can result in graft occlusion, ischemia, and inability to visualize the distal lesion. We report three cases in which treatment of such lesions was successfully completed using two guiding catheters, one of which was used for lesion visualization and one for equipment delivery. J INVASIVE CARDIOL 2010;22:E78–E81 Key words: percutaneous coronary intervention, coronary artery bypass grafts, tortuosity, internal mammary artery Because of its excellent long-term patency, at least one internal mammary artery (IMA), usually the left (LIMA), is currently used in nearly all coronary artery bypass graft operations (CABG). ¹ If occlusive disease develops in the IMA target native coronary artery, percutaneous coronary intervention (PCI) through the IMA graft may be required. However, wiring of an IMA graft may result in occlusion due to pseudo-lesion formation ² or dissection. ^3,4 Apart from causing ischemia, IMA occlusion may prohibit visualization and PCI of the distal target lesion. We describe a “dual-guiding catheter” technique for successful completion of native coronary artery PCI through tortuous IMA grafts. Case 1. A 58-year-old male presented with unstable angina and anterior ischemia on nuclear stress testing. He had undergone CABG 2 years prior to admission, with implantation of a LIMA to the mid-left anterior descending artery (LAD) and a saphenous vein graft (SVG) to the first obtuse marginal branch (OM1). Coronary angiography through the right femoral artery access showed a patent SVG to OM1, a patent but tortuous LIMA to LAD (Figures 1A and B), a patent right coronary artery (RCA), severe stenosis in the left main and proximal circumflex arteries, and a significant LAD lesion distal to the LIMA anastomosis (Figures 1A and B). A decision was made to attempt PCI of the distal LAD lesion via the LIMA. Anticoagulation was obtained with bivalirudin. The LIMA was engaged with a 90 cm 6 French (Fr) IMA guiding catheter. We experienced significant difficulty wiring the LIMA (Figure 1C), but were eventually successful using a Fielder guidewire (Abbott Vascular, Santa Clara, California) over a Prowler 45 Microcatheter (Cordis Neurovascular, Warren, New Jersey). Post-wiring LIMA angiography revealed no antegrade flow past the proximal LIMA (Figure 1D). Repeat LIMA angiography after removal of the Fielder guidewire (leaving the soft Prowler microcatheter in place) showed persistent LIMA occlusion. Left femoral artery access was obtained and the left main coronary artery was engaged with a 7 Fr EBU 3.75 guiding catheter (Medtronic Vascular, Santa Rosa, California) that showed TIMI 3 antegrade LAD flow (Figure 1E). The LAD was wired through the EBU guide and the LIMA wire was withdrawn, restoring TIMI 3 LIMA antegrade flow (Figure 1F). Due to competitive flow from the LIMA, native LAD injections via the EBU guide could not visualize the distal LAD lesion. LAD PCI was performed delivering equipment via the left main guiding catheter while visualizing the distal LAD lesion via injections through the LIMA guiding catheter (Figure 1G). The distal LAD was predilated with a 2.5 x 10 mm balloon and stented using a Promus 2.5 x 12 mm everolimus-eluting stent (Boston Scientific Corp., Natick, Massachusetts). Final angiography revealed an excellent result in the distal LAD and TIMI 3 antegrade LIMA flow (Figure 1H). The patient had an uneventful recovery and remained symptom-free throughout 10 months’ follow up. Case 2. A 49-year-old male presented with unstable angina and was found to have anterior and inferior ischemia on dobutamine stress echocardiography. Two years prior, he had undergone CABG. Coronary angiography through the right femoral artery revealed a proximal LAD occlusion, severe stenosis of the mid circumflex and proximal RCA, an occluded SVG to the right posterolateral branch, a patent SVG to first diagonal, a patent radial graft to the OM1, and a patent LIMA to the LAD (Figure 2A) with a 90% LAD stenosis distal to the LIMA anastomosis (Figure 2B). A decision was made to proceed with multivessel PCI. Anticoagulation was obtained with bivalirudin. The proximal RCA and PDA were stented with a 2.5 x 12 mm and a Xience V 3.0 x 15 mm everolimus-eluting stents (Abbott Vascular) without complications. The LIMA was subsequently engaged with a 90 cm 6 Fr IMA guiding catheter. After a Whisper guidewire (Abott Vascular) was advanced through the LIMA to the distal LAD, the LIMA antegrade flow stopped. Left femoral arterial access was obtained and the SVG to diagonal was engaged with a 6 Fr LCB guiding catheter showing continued LAD filling through the SVG (Figure 2C). PCI of the distal LAD was then performed, delivering equipment through the LIMA guiding catheter and visualizing via injections through the SVG to diagonal branch guiding catheter. The distal LAD lesion was predilated with a 2.0 x 12 mm balloon and successfully stented with a Xience V 2.5 x 12 mm everolimus-eluting stent (Abbott Vascular) (Figure 2D). The LIMA wire was then removed restoring TIMI 3 antegrade flow (Figure 2D). The patient was dismissed the following day and has remained angina-free at 7-month follow up. Case 3. A 62-year-old male presented with severe exertional angina despite maximal medical therapy. He had undergone CABG 9 years prior to presentation with implantation of a LIMA to mid-LAD, a RIMA-to-RCA, and a SVG-to-diagonal. Angiography revealed significant stenosis of the RCA, the first obtuse marginal and the proximal LAD. The LIMA had a high-grade stenosis at the LAD distal anastomosis (Figure 3A) and was tortuous (Figure 3B). The RIMA-to-RCA and SVG-to-diagonal grafts were both patent. PCI of the LIMA distal anastomotic lesion was planned. Anticoagulation was obtained with unfractionated heparin. The LIMA was engaged with a 90 cm 6 Fr IM guiding catheter and was wired with a Whisper wire, resulting in TIMI 1 antegrade flow (Figure 3C). Contralateral femoral access was obtained and the LMCA was engaged using an XB 3.5 guiding catheter (Figure 3D), allowing visualization of the LIMA-LAD anastomosis. The lesion was predilated (via the IM guiding catheter) with a 2.0 x 12 mm and a 2.5 x 20 mm balloon and stented with an Xience V 2.5 x 23 mm everolimus-eluting stent. Following removal of the Whisper wire, the distal LIMA lesions persisted and were successfully treated with 2 additional Xience V overlapping everolimus-eluting stents (Figure 3E). The patient’s angina resolved and he has remained symptom-free throughout 6 months of follow up. Discussion. Our cases demonstrate a “dual-guiding catheter” technique for overcoming IMA occlusion when PCI of a target native coronary artery is attempted through an IMA coronary bypass graft. Simultaneous use of two guiding catheters (one engaging the IMA and another engaging the native or bypass vessel that also supplies the IMA-supplied territory) can allow separate equipment delivery and target lesion visualization (Table 1) and successful completion of the PCI. Attempting PCI through an IMA graft is associated with four major technical challenges. First, IMA grafts may be difficult to engage. Second, IMA grafts can be long and interventional equipment may not be long enough to reach the target lesion. Third, IMA grafts can often be markedly tortuous, which may make wiring difficult. Fourth, antegrade IMA graft flow may cease after wiring. The first challenge, engaging the IMA, can be addressed by using various guiding catheters (such as IM, JR4, or modified IM), and occasionally using a guidewire as a rail for pulling the guiding catheter into the IM ostium. Alternatively, a diagnostic catheter (which is stiffer compared to a guiding catheter) may be used to engage the IM ostium, insert an exchange length wire in the LIMA, followed by exchange of the diagnostic catheter for a guiding catheter. ⁵ If all else fails, an ipsilateral radial or brachial approach can allow IMA graft engagement. The second challenge, reaching the target lesion in patients with long IMA grafts, could be addressed by using shorter guiding catheters, shortening the guiding catheters, ⁶ or using longer shaft balloons and stents. The third challenge, difficulty wiring the IMA, may be addressed by using hydrophilic, polymer-jacket or transitionless guidewires, flexible microcatheters, such as the Transit (Cordis), Prowler (Cordis), Progreat (Terumo Medical Corp., Sumerset, New Jersey), Finecross (Terumo), and Renegade (Boston Scientific), over-the-wire balloons, or deflectable-tip catheters, such as the Venture catheter (St. Jude Medical, Minneapolis, Minnesota), although the latter has a stiff shaft and may cause pseudo-lesions. ^4,7 Addressing the fourth challenge (antegrade flow cessation after wiring) can be difficult. Although antegrade IMA flow cessation after wiring is usually caused by vessel “kinking” and pseudo-lesion formation, it can also be caused by dissection (as likely occurred in our third case). Sharma et al proposed a technique of removing the guidewire over a flexible microcatheter to minimize the LIMA “accordioning” and to restore antegrade flow. ³ However, this technique failed in the first patient of our series, in whom a Prowler microcatheter caused persistent LIMA occlusion, in spite of removing the guidewire. Also, this technique could render stent delivery or balloon angioplasty challenging if there are no angiographic landmarks (such as clips), due to poor visualization. Rigatelli et al recently reported use of a “double-access technique” for performing LAD PCI in a mammary graft recipient.8 In the present manuscript we demonstrate use of a “dual-guiding catheter technique”, in which a second arterial access is obtained and a second guiding catheter is used to engage either the native target coronary artery (if it is patent) or another bypass graft that supplies the target artery. The second guiding catheter can be used either for balloon and stent delivery (as in Case 1) or for lesion visualization (as in Cases 2 and 3). The “dual guide catheter” technique has limitations. First, it requires that the target native coronary artery be supplied not only by the IMA graft but also by another vessel (either a native coronary artery as in Cases 1 and 3 or by another bypass graft, as in Case 2). If the target vessel is only supplied by the IMA graft then immediate wire removal may be required if the patient develops IMA occlusion with angina, electrocardiographic changes, or hemodynamic instability. An alternative solution in those cases would be to perform antegrade PCI of the native coronary chronic total occlusion, using LIMA injections to help direct and verify position of the antegrade wiring into the true distal lumen. Tenzig et al performed antegrade crossing of a proximal LAD chronic total occlusion after failing to traverse a LIMA graft due to tortuosity. They were then able to deliver equipment into the distal LAD with visualization via the LIMA. ⁹ Second, the “dual-guiding catheter” technique requires obtaining an additional arterial access, which may be challenging in patients with peripheral arterial disease. Moreover, obtaining arterial access during PCI after anticoagulation has been administered may carry an increased risk of vascular access complications. Therefore, in patients with tortuous IMA grafts who do have an additional vessel supplying the target artery, it may be best to obtain a second arterial access before attempting IMA wiring (Figure 4). While the current case series describes using the “dual-guiding catheter” technique in tortuous LIMA grafts, it can also be applied to tortuous right internal mammary grafts (RIMA). Due to the longer distance between the RIMA pedicle and the native coronary artery anastomosis, RIMA grafts are longer than LIMA grafts, but are also frequently equally tortuous and can develop pseudo-lesions and flow cessation similar to LIMA grafts, that could be addressed using the dual-guiding catheter technique. Moreover RIMA engagement can be more challenging than LIMA engagement in cases of excessive brachiocephalic trunk tortuosity. ⁵ In summary, although a guiding catheter usually simultaneously performs two roles (target lesion visualization and interventional equipment delivery), “separating” these two roles, as in the “dual-guiding catheter” technique, might be necessary to successfully perform interventions through tortuous IMA grafts.

References

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_______________________________________________________________ From the *VA North Texas Healthcare System and §University of Texas Southwestern Medical Center, Dallas, Texas. Disclosures: E. S. Brilakis has received speaker honoraria from St. Jude Medical, consulting fees from Medicure and research support from Abbott Vascular. S. Banerjee has received speaker honoraria from St. Jude Medical, Medtronic, and Johnson & Johnson and research support from Boston Scientific and The Medicines Company. Manuscript submitted September 3, 2009, provisional acceptance given October 18, 2009 and final version accepted October 22, 2009. Address for correspondence: Emmanouil S. Brilakis, MD, PhD, FSCAI, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. E-mail: esbrilakis@yahoo.com