Case Report - (2019) Volume 5, Issue 2
1Division of Endovascular Therapy, Pontificia Universidad Católica de Chile, Santiago, Chile
2Division of Interventional Cardiology, Hospital Sótero del Río, Santiago, Chile
Received date: October 21, 2019; Accepted date: November 4, 2019; Published date: November 11, 2019
Citation:Hameau DR, Fuensalida AA, Muñoz DR, Valdebenito TM, Winter DJ, et al. (2019) When Shorter is Better: A Novel Technique for Shortening a Guide Catheter without Losing Guidewire Position. Interv Cardiol J Vol.5 No.2:3
Background: The retrograde approach for percutaneous interventions of chronic total occlusions (CTO) is a challenging technique but it has helped to improve the overall success rates. Even with the use of specialized materials like short guide catheters and longer microcatheters or balloons, sometimes operators cannot obtain the sufficient length to reach the target lesion.
Description: We a retrograde intervention through a saphenous vein graft (SVG) where the CTO lesion was crossed with the guidewire but could not advance the rest of the equipment (microcatheter nor balloons) due to the length of the SVG. Guide catheter was shortened with a technique that uses the introducer needle as a shield to protect the guide wire and maintains position at all times. Then a radial sheath was connected directly to catheter to continue the procedure in a standard way.
Conclusion: The need for shortening a guide catheter is an uncommon situation during a CTO intervention and it can be really challenging in the scenario where the guideword is already across the lesion. In these cases, operators must know how to perform it quickly and safely. We describe a novel technique for shortening a guide catheter that is easy to learn and provides a helpful tip for this bailout situation.
Percutaneous interventions; Chronic total occlusions
A chronic total occlusion (CTO) is defined as the complete obstruction of a coronary artery, exhibiting TIMI 0 or TIMI 1 flow for at least 3 months. CTOs are a common finding in almost 15- 25% of the patients with stable angina [1] and they present a technically challenging scenario. Since its original description in 2006 by the Toyohashi Heart Center [2], the retrograde approach for CTO PCI has become widespread all over the world with its utilization steadily increasing to almost 29.9% in 2015 [3] and success rates close to 85-88% [4].
Despite increasing improvements in the operator`s skills and the development of specialized material, it`s not always possible to prepare in advance for the difficulties one might find in the procedure. During the beginning of the retrograde CTO PCI development, guide catheters were usually shortened before the procedure and nowadays it is an uncommon situation when working with the proper material. However, operators might still found themselves in situations where there is the need for shortening a guide catheter during a retrograde approach or even have to do so with the guidewire already across the lesion. There is a lack of knowledge on how to adequately solve this issue and very few publications address the technical details to accomplish it.
We introduce a simple technique to solve this situation without sacrificing the guidewire position.
We present the case of a 60-year-old male, with a past medical history of type 2 Diabetes Mellitus, Hypertension, obesity, and coronary artery disease. The patient had undergone coronary artery bypass graft surgery (CABG) in 2005 with a Left internal mammary artery graft to the left anterior descending artery (LIMA-LAD), saphenous vein graft to the posterior descending artery of the right coronary (SVG – PDA RCA) and a saphenous vein graft to the circumflex artery (SVG-ACx).
He also had a proximal chronic total occlusion (CTO) of the native circumflex and 2 previous percutaneous coronary interventions (PCI) to the SVG-Cx with drug-eluting stents (2017-2018). 6 months later, the patient presented with occlusion of SVG-Cx due to a neoatherosclerotic ruptured plaque. Only plain balloon angioplasty (POBA) was performed to restore flow through the SVG and staged revascularization of the native ACx was planned in the following 48 hours. The first attempt to recanalize the CTO with an antegrade approach was unsuccessful due to a proximal dissection so the patient was referred to our center for a new procedure.
Upon arrival, the case was discussed for proper planning. The previous angiography was analyzed for characterization of the CTO, showing a tapered proximal cap, an occlusion length of 21 mm, the distal vessel was clear and collaterals were coming mainly from the SVG. The J-CTO score was 2 (Figure 1). The Interventional team planned a second attempt using a retrograde approach.
Figure 1: Characterization of the CTO. Target Vessel: Native CX; Proximal cap: Tapered; Length: 18mm; Distal vessel: Clear; Colaterals: From SVG.
Using bi-radial access, a 6F 100 cm AR2 guide catheter (Medtronic, Minneapolis, USA) was placed in the SVG – Cx (which was not shortened before the procedure) and a 6F 100 cm EBU 3,5 guide catheter in the Left main. Using a retrograde approach, we advanced a Run-through guidewire (Terumo, Tokyo, Japan) over a 150 cm Caravel microcatheter (Asahi, Tokyo, Japan) through the SVG. Then we exchanged guidewire to a Fielder XT-R (Asahi, Tokyo, Japan) and were able to cross the CTO lesion but due to the length of the SVG, we couldn´t advance the microcatheter nor any balloons available (Figure 2).
Figure 2: Caravel microcatheter was unable to move further across de CTO lesion due to insufficient length. Guide catheter needed to be cut to continue the procedure.
The shortest guide catheter in the cath lab was used and guidewire extensions to exteriorize the Fielder XT-R were not available so we faced the challenge of having to cut the AR2 with the guidewire inside to continue the procedure.
The technique for solving this problem is described ahead: First, remove the Y-connector and insert the introducer needle (Figure 3A) while keeping the guidewire inside the guide catheter. At this point, a Kelly clamp can be placed more distally on the guide catheter to minimize back bleeding. Then cut the guide catheter without damaging the guidewire by cutting at a point where it is protected by the introducer needle (Figure 3B). This should be accomplished with surgical scissors instead of a scalpel to obtain a straight cutting line (Figure 3C). After cutting, the introducer needle was pulled out along with the proximal part of the guide catheter that was removed, leaving the shortened part of the catheter with the guidewire still in place (Figure 3D). There is also the possibility to use the same strategy and keep shortening the guide catheter as long as we need to by inserting the introducer needle again (Figure 4A) and cutting over it (Figure 4B-C).
Figure 3:(A) Start the procedure by removing the Y connector and inserting the guidewire through the introducer needle. (B) Detailed diagram of the connection. (C) Use scissors to cut the guide catheter at a point where the guidewire is protected by the needle. (D) The proximal part of the guide catheter is removed after the cutting.
Figure 4:(A) Remove the tip of a 5F radial sheath. (B) Inserting the introducer needle through the hemostatic valve allows getting the guidewire through it without any damage. (C) Assemble the system.
After that, cut the tip of a 5F radial sheath (one size smaller than the guide catheter) (Figure 5A) and insert the introducer needle through the hemostatic valve (Figure 5B). This will allow assembling the device by inserting the proximal end of the previously cut catheter into the radial sheath (Figure 5C). Finally, connect the side port of the radial sheath to the manifold.
Figure 5:(A) Remove the tip of a 5F radial sheath. (B) Inserting the introducer needle through the hemostatic valve allows getting the guidewire through it without any damage. (C) Assemble the system.
After cutting the catheter, operators were able to advance the microcatheter further into the LAD (Figure 6A). Then exchanged the Fielder XT-R for a workhorse guidewire and proceeded like a standard PCI by deploying 2 drug-eluting stents (Figure 6B).
Figure 6:(A) After shortening the catheter, the microcatheter was being advanced further into the left anterior descending artery. (B) Final result of the procedure.
In this case report, we present a novel technique for shortening a guide catheter during a retrograde CTO PCI with the guidewire already across the lesion.
Currently, the need for shortening a guide catheter is a rare situation especially because of the development of specialized CTO material. The standard length of guide catheters is 100 cm or even >100 cm in cases of a tortuous aorta, however, most manufacturers include specific CTO material in their stock suchas short 80-90 cm guide catheters and longer microcatheters 150 cm ( compared to the standard 135 cm), guidewires or balloons. Unfortunately, this might not always be enough to reach the culprit lesion. The mismatch in length between a guide catheter and balloons or microcatheters is most likely encountered in long bypass grafts and with target lesions in the distal native vessel. In this case, there wasn´t a shorter catheter available in the cath lab and the need to cut it even more before the procedure was underestimated by the operator.
We describe a sequence for cutting a guide catheter with the guidewire inside and then connect it directly to a 5F radial sheath. This technique allows better torque control by having a smaller radial sheath attached to the proximal part of the catheter instead of the same guide catheter reattached to the distal part. Using the hemostatic valve from a radial sheath instead of the Y connector has been proposed by Antonellis et al. [5] as a safe alternative and without any significant disadvantages in a series of 350 patients.
We also must reinforce the concept of using scissors to avoid creating an irregular surface at the end of the catheter and obtain a plane free of spikes at the connecting point.
Another advantage of this method includes maintaining the position of the guidewire at all times, being simple to perform by using the same introducer needle of the kit (it takes less than 45 seconds to fully connect the system) and that it protects the guidewire from being damaged during the cutting process. Also, the use of the introducer needle to assemble the system can prevent the back of the guidewire from damaging the hemostatic valve of the hub when trying to get it through.
This technique may provide useful when there is the need to perform a CTO PCI and the operator.
One of the first shortening techniques was described by Stratienko [6] in 1993 but it didn`t include guidewire protection and the cutting was performed with a scalpel instead of scissors. Another common solution is to cut the guide catheter and use a piece of the radial sheath as a connector for both parts but this is generally performed outside the patient´s body, before the procedure starts, and, in our experience, it can affect torque control.
The main disadvantage of using a 5F radial sheath is that it doesn’t allow for complex 2 stent techniques but it can be a bailout solution for simple, single stent, procedures. This limitation can be overcome when larger catheters and sheaths are used.
In conclusion, we describe a novel technique for shortening a guide catheter that can be applied safely in rescue situations and it could provide a helpful tip for CTO PCI operators.
The authors would like to acknowledge Ms. María Mestas, Jenny Pineda, Javiera Ormeño, Cecilia Aguayo, Maura Rivero, Geanella Talenti and Daniela Fuenzalida for their contribution during the procedure and development of this manuscript.
No funding was needed for this publication.
The authors have no conflicts of interest to declare.
