A 67-year-old male with a history of type II diabetes mellitus and hypertension transferred from the outlying facility due to confusion and mid epigastric pain of two days duration. Vital signs were notable for blood pressure 156/77 mmHg and a heart rate of 110 beats per minute. Physical examination was unremarkable except for tachycardia, diminished breath sounds in the lower lung fields, and bilateral lower extremity pitting edema. The patient’s lab workup revealed an elevated white blood count of 31.3 K/µL (reference range: 4.0-11.0 K/µL) with bands, elevated troponin of 9.53 ng/mL (reference range: 0.00-0.03 ng/mL), brain natriuretic peptide (BNP) of 1563 pg/mL (reference range: 0-100 pg/mL) and creatinine of 1.85 mg/dL (reference range: 0.50-1.30 mg/dL). An electrocardiogram showed sinus tachycardia with 1 mm ST-segment depression in leads I, V4, and V5. Echocardiogram showed an ejection fraction of 50-55% without regional wall motion abnormalities. He was admitted with a diagnosis of sepsis with hypotension, Hemophilus influenzae pneumonia, and lower extremity cellulitis. The patient was in respiratory failure and required intubation. Five days after the patient improved, a coronary angiogram was performed through right radial access, revealing a mid right coronary artery (RCA) calcified 80% stenosis and an acute thrombotic occlusion of the right posterolateral (rPL) artery with TIMI 0 to 1 flow (Figure 1A-B). The left coronary system showed a patent left main coronary artery, 30% distal left anterior descending artery stenosis, 70% mid left circumflex artery stenosis, 99% proximal total occlusion of the 1st obtuse marginal (OM), and 99% mid total occlusion of the 2nd OM.
Due to the acute thrombotic lesion of rPL artery with decreased coronary blood flow, we proceeded with intervention. Through the right radial access, a 6 French (Fr) Amplatz left (AL) 0.75 guide catheter was used to engage the right coronary ostium. A Balance Middleweight (BMW) II .014-inch wire (Abbott Vascular) was used for wiring the lesion. The initial wiring of the rPL artery was difficult because of the tortuosity of the RCA, leading to a lack of support and gritty sensation during advancement due to severe coronary artery calcification. Thus, we planned to stent the mid RCA first and then use a GuideLiner (Teleflex) for the support to reach the distal rPL lesion. A Trek Rx 2.0 x 12 mm balloon (Abbott Vascular) was inflated at 18 atmospheres (atm), followed by 22 atm, in order to predilate the mid RCA stenosis. Further balloon dilation was necessary and a 6 Fr GuideLiner was used to deliver an NC Trek 3.00 x 15 mm balloon to the site. The Trek balloon was inflated at 18 atm, followed by a 20 atm inflation. A Xience Sierra 4.0 x 28 mm drug-eluting stent (Abbott Vascular) was delivered at 22 atm in the mid RCA though the inchworm technique1 (Figure 2). However, we were still unable to wire the distal acute rPL lesion and the wire was prolapsing into the right posterior descending artery (Figure 3). A Corsair Microcatheter (Asahi Intecc) was advanced over a Pilot 50 .014-inch wire (Abbott Vascular) and exchanged with a BMW wire (Figure 4A-B). We performed pre dilation with a Trek Rx 2.0 X 15 mm balloon in the mid rPL artery at 18 atm and in the proximal rPL artery at 20 atm. We deep intubated the GuideLiner to deliver a Euphora 2.0 x 15 mm NC Rx (Medtronic) and then for further pre dilatation, a Euphora Rx 2.5 x 12 mm (Figure 5). A Resolute Onyx 3.0 x 12 mm stent (Medtronic) was deployed at 18 atm in the rPL with restoration of TIMI-3 flow (Figure 6A-B). The final angiographic result was excellent and without complications. The patient was discharged on the following day.
Complex coronary anatomy can pose a significant challenge to the delivery of percutaneous coronary intervention (PCI) equipment. Due to the lack of support, the wiring of a distal lesion can be challenging in a coronary artery with diffusely calcified tortuous anatomy proximally. The GuideLiner catheter (Teleflex) is one of several devices that can provide additional backup support and help with distal device delivery in challenging coronary lesions.2,3 To achieve a successful PCI outcome, deep-vessel intubation with a guiding catheter extension to deliver the coronary balloons and stents would be required, as in our case.
The flexibility of the GuideLiner assists in reaching the target lesion in a difficult-to-wire coronary artery by providing extra backup support, and it also allows the delivery of balloons and stents distally. Possible complications with the GuideLiner can occur, especially in deep vessel intubation, such as stent deformation while advancing or withdrawing, stent dislodgement, iatrogenic coronary artery dissection, air embolism, and pressure dampening.3
Our case demonstrates extreme deep-vessel intubation of the GuideLiner. We were able to reach a complex lesion in the rPL artery despite a long, diseased segment in the RCA and successfully deliver high-profile balloons and stents distally through transradial access. There were no procedure-related complications.
Disclosure: The authors report no conflicts of interest regarding the content herein. All authors had access to the data, participated in the preparation of the manuscript, and approved this manuscript.
The authors can be contacted via Maheedhar Gedela, MD, at firstname.lastname@example.org.
Read the second case in the series:
- Singh J, Shpiegel A. In-stent restenosis: tools and techniques. In: Coronary in-stent restenosis: an algorithmic approach to diagnosis and treatment. J Invasive Cardiol. 2019 (Suppl). Available as a pdf online at https://www.invasivecardiology.com/sites/invasivecardiology.com/files/2019-10/PhillipsSupplement_JIC1019_v3web_0.pdf. Accessed September 16, 2020.
- Waterbury TM, Sorajja P, Bell MR, et al. Experience and complications associated with use of guide extension catheters in percutaneous coronary intervention. Catheter Cardiovasc Interv. 2016;88(7):1057-1065. doi:10.1002/ccd.26329
- Fabris E, Kennedy MW, Di Mario C, et al. Guide extension, unmissable tool in the armamentarium of modern interventional cardiology. A comprehensive review. Int J Cardiol. 2016;222:141-147. doi:10.1016/j.ijcard.2016.07.168