Guide extension, unmissable tool in the armamentarium of modern interventional cardiology. A comprehensive review

Utility of Guiding Catheter Extensions for Recanalization of Chronic Total Occlusions: A EuroCTO Club Expert Panel Report

Guiding catheter extensions (GCEs) have become indispensable tools in the modern approach to percutaneous coronary intervention (PCI). The support offered during complex PCI of uncrossable, or tortuous lesions is particularly valuable in the setting of chronic total occlusions (CTO), both for conventional anterograde wire escalation and for anterograde or retrograde dissection and re-entry techniques. This EuroCTO consensus document describes the use of GCE during CTO recanalization and provides a practical guide to anatomies and techniques in which these devices are applicable. We describe the peculiar features of the most-used device and the practical technique for GCE delivery in standard PCI; further specific indications for antegrade and retrograde CTO PCI are discussed in a specific section. In the antegrade approach, the GCEs may be useful to increase support or facilitate antegrade dissection and re-entry techniques, while in the retrograde approach for reverse controlled antegrade and retrograde tracking, to increase retrograde support for gear delivery, for treatment of CTO in bifurcation and ipsilateral externalization with a single guide catheter. The last section of the paper describes GCE-related complications, challenges, limitations, and future perspectives.

Rare complications of Guideplus guide-extension catheter during complex percutaneous coronary intervention

Guide-extension catheters (GECs) are effective in providing reinforced backup support and coaxial alignment, leading to successful complex percutaneous coronary intervention (PCI). However, several GEC-associated complications have been reported, including coronary injuries, thrombotic events, and GEC fractures. The Guideplus GEC (Guideplus II ST; Nipro, Osaka, Japan) has a higher crossability due to its unique hydrophilic-coated soft cylinder, which is frequently used in complex PCI for diffuse, tortuous, and heavily calcified lesions. We describe two cases of Guideplus GEC-associated complications during complex PCI: Case 1 with a radiopaque marker dislodgement and Case 2 with a stent dislodgment. In both cases, the Guideplus GEC was used within 7-Fr guiding catheters, employing the mother-and-child technique. A large inner-catheter gap between these catheters caused by a positioning bias due to arterial bends (the aortic arch in Case 1 and brachiocephalic arterial bends in Case 2) may have caused these complications due to its interference with coronary devices (the trapping balloon in Case 1, and the scoring balloon in Case 2). Early cognition and management of these potential Guideplus GEC-associated complications are important to prevent further deterioration.

Learning objectives

The Guideplus guide-extension catheter (GEC) with a hydrophilic-coated soft cylinder can deliver coronary devices to complex lesions owing to its high crossability. However, delivering coronary devices with the Guideplus GEC should be carefully performed because a large inner-catheter gap between Guideplus GEC and a guiding catheter may occur if a proximal port of the Guideplus GEC is located at an arterial bend. In such settings, Guideplus GEC-associated complications must be carefully observed, including radiopaque marker dislodgement and stent dislodgement.

Utility of coronary orbital atherectomy with guide-extension system for distally located undilatable in-stent restenosis: A case report

Orbital atherectomy (OA) may be effective in managing undilatable in‐stent restenosis (ISR) despite off‐label indications. We demonstrated that optical frequency domain imaging (OFDI)‐guided OA, with a guide‐extension system was effective even in distally located, undilatable ISR. However, OFDI revealed that inter‐struts calcified neoatherosclerosis remained a challenging issue.

Feasibility of kissing balloon technique through guide extension catheters: an experimental bench test

Previous reports showed that GuideLiner (GL) and Guidezilla (GZ) can accommodate bulky and multiple devices beyond the official profiles. However, feasibility of kissing balloon technique (KBT) through these devices is unknown. The tested devices included 7Fr-GL/GZ and respective three types of 2.5 mm semi-compliant (SC) and non-compliant (NC) balloons: conventional model (CM), tapered-tip model (TM) and latest model (LM). First, three experienced operators attempted to advance all 21 combinations of the 2 balloons through GL/GZ on the guidewires and assessed the crossability in 3 grades: easy, difficult and impossible. Second, the only balloon combinations graded as easy by all operators were tested in the polyurethane-made bifurcation model which required KBT following cross-over stenting. Within the total of 42 device combinations, only one balloon combination of double LM-NC balloons was classified as easy in both GL/GZ by consensus opinion of the operators. While two combinations of LM-SC and LM-SC/NC balloons were classified as difficult in both GL/GZ, all four combinations of LM-SC/NC and CM/TM-NC balloons were classified as difficult only in GL. Other 32 combinations were all classified as impossible. In the bifurcation model, the combination of double LM-NC balloons using GL achieved KBT while the same balloon combination with GZ failed. The feasibility of KBT using child-catheter is highly dependent on the device characteristics. The combination of latest small-profile NC balloons through GL could be clinically applicable.

From debulking to delivery: sequential use of rotational atherectomy and Guidezilla™ for complex saphenous vein grafts intervention

Background

Percutaneous coronary interventions (PCI) of old calcified saphenous vein grafts (SVGs) is challenging and is associated with a considerably high risk of adverse ischemic events in the short- and long-term as compared to native coronary arteries. We report a case in which a non-dilatable, calcified SVG lesion is successfully treated with rotational atherectomy followed by PCI and stenting with local stent delivery (LSD) technique using the Guidezilla™ guide extension catheter (5-in-6 Fr) in the “child-in-mother” fashion.

Case presentation

A 70 years-old man with a dilated ischemic cardiomyopathy, triple coronary artery bypass grafting (CABG) in 1990 and chronic renal failure (baseline GFR: 45 ml/min/1.73 m²) underwent a coronary angiography for a Non-ST segment elevation myocardial infarction (NSTEMI). Native coronary circulation was completely occluded at the proximal segments. Grafts angiography showed a tandem calcified lesions of SVG on distal right coronary artery (RCA) and an ostial stenosis of the SVG on first obtuse marginal branch (OM1). Left internal mammary artery on the mid left anterior descending artery was patent. Ad Hoc PCI of SVG on RCA was attempted. The proximal calcified stenosis has been crossed with a 1.5 x 12 mm balloon only with the support of Guidezilla™, however the non-compliant (NC) balloon 2.5 x 15 mm was unable to break the hard and calcified plaque. After several attempts, the procedure was interrupted with a suboptimal result. An elective transradial PCI of SVG on RCA with rotational atherectomy was performed. Two runs with 1.25 mm burr and 2 runs with 1.5 mm burr were carried out. Then, the use of distal anchoring balloon warranted support and tracking, made as centring rail for the advance of the tip of the “mother-and-child” catheter into the SVG. During slow deflation of the balloon, the Guidezilla™ was advanced distal to the stenoses to be stented, thus allowing the placement of two long drug eluting stents according to a LSD technique.

Conclusions

Rotational atherectomy is a feasible option for non-dilatable stenoses in old SVGs when there is no evidence of thrombus or vessel dissection and the subsequent use of “mother-and-child” catheter has a key role, especially in case of radial approach, for long stents delivery.

A "Jail Escape Technique" (JET) for distal side branch wiring during provisional stenting: Feasibility and first-in-man study

OBJECTIVE

To evaluate the feasibility of a novel technique for achieving distal SB access and improve strut apposition during provisional stenting.

BACKGROUND

While distal rewiring and stent expansion toward the side branch (SB) are associated with better results during provisional stenting of coronary artery bifurcation lesions, these techniques are technically challenging and often leave unopposed struts near the carina.

METHODS

The "Jail Escape Technique" (JET) is performed by passing the proximal tip of the SB wire between the main vessel (MV) stent struts and balloon before implantation, allowing the MV stent to push the SB wire against the distal part of the carina. The MV stent can then be deployed without jailing the SB wire. Distal SB access and strut distribution at the carina were tested in phantom and swine models. Stent distortion, dislodgement forces, and material damage were evaluated with tensile testing. Human feasibility was then tested on 32 patients.

RESULTS

Preclinical testing demonstrated that the SB wire was located at the most distal part of the carina and no strut malapposition at the carina was present after balloon inflation. Stent distortion, dislodgement forces, or material damage were not affected. JET was successfully performed in 30 of 32 patients. No major adverse cardiovascular events occurred in any patient at 6-month follow-up.

CONCLUSION

The "JET" enables distal SB access and eliminates strut malapposition at the carina. Further studies with larger numbers of patients are needed to further investigate this technique.

The GuideLiner catheter: A supportive tool in percutaneous coronary intervention of chronic total occlusion

Background

Failure of delivering a stent or a balloon across the target lesion during percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), especially in arteries with calcified tortuous anatomy, is often due to insufficient backup support from the guiding catheter. The purpose of this study was to assess the feasibility of the GuideLiner (GL) catheter use.

Methods

We examined 18 patients and used the GL catheter to overcome poor support and excessive friction in standardized antegrade and retrograde CTO procedures. The GL is a coaxial, monorail guiding catheter extension delivered through a standard guiding catheter and is available in different sizes.

Results

Almost all lesions were classified as severely calcified (94.4 ± 0.24%). The Japanese CTO score reflecting lesion complexity was 3.56 ± 0.78. All procedures were performed femorally; the retrograde approach was used in 27.8 ± 0.46% of cases. The overall success rate was 88.9 ± 0.32%; there were no relevant complications.

Conclusions

The GL catheter is an adjunctive interventional device which enhances and amplifies CTO-PCI. Its use is indicated in cases in which back-up force needs to be strengthened to pass a CTO despite advanced calcification. It can be recommended as an important additional tool in advanced interventional cardiology such as antegrade and retrograde CTO-PCI if other techniques like anchor balloon or anchor wire are not possible.