Case Series

Case #2: The Need for a Guide Catheter Extension: Percutaneous Coronary Intervention of a Diffusely Diseased Anomalous Right Coronary Artery

Aditya Singh,1 MD; Maheedhar Gedela,1 MD; Tomasz Stys,2 MD, Adam Stys,2 MD

University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota

1Cardiovascular Fellow, Sanford Cardiovascular Institute; 2Professor of Medicine, Sanford Cardiovascular Institute

Aditya Singh,1 MD; Maheedhar Gedela,1 MD; Tomasz Stys,2 MD, Adam Stys,2 MD

University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota

1Cardiovascular Fellow, Sanford Cardiovascular Institute; 2Professor of Medicine, Sanford Cardiovascular Institute

Read the introduction to this case series –

Telescopic Guide Catheter Support:
A Silent Revolution


Read Case #1: A Deep Dive With a Guide Catheter Extension in a Severely Calcified Tortuous Right Coronary Artery in Non-STEMI


Case Report

A 62-year-old male with a history of medically managed non-ST segment elevation myocardial infarction (NSTEMI) in 2014, hypertension, hyperlipidemia, and a former smoker presented to the hospital with a sudden onset of worsening substernal chest pain and shortness of breath of one-day duration. He had been admitted for an NSTEMI 4 years prior, with the culprit lesion being an anomalous high take-off of the right coronary artery (RCA) from the left coronary cusp. Intervention had been attempted on the RCA lesion. Multiple guide catheters had been used to engage the RCA. Although the wiring was performed without ostial engagement with the guide catheter, medical management was deemed appropriate, due to the infeasibility at that time of passing coronary balloons and stents. At his current presentation, the patient noted off-and-on chest tightness and shortness of breath over the past two months, and a history of cough and chills of a 1-week duration. Physical examination revealed a temperature 97.6˚F, heart rate of 71 beats/min, blood pressure 119/77 mmHg, and oxygen saturation 95% on 2 L/min through a nasal cannula. The remaining physical examination was unremarkable, except for faint bilateral crackles on auscultation. Lab work revealed a peak troponin I of 12.28 (reference range: 0.00-0.03 ng/mL) and brain natriuretic peptide (BNP) of 398 pg/mL (reference range: 0-100 pg/mL). His electrocardiogram revealed 1.0 mm ST-segment depressions in leads V4 through V6, and non-specific T wave flattening in the lateral precordial and limb leads (Figure 1). A computed tomography angiogram of the chest revealed a right upper lobe consolidation and no evidence of acute pulmonary embolism. An echocardiogram showed a normal left ventricular ejection fraction of 54% and inferior akinesis. After the diagnosis of right upper lobe pneumonia, the patient was started on broad-spectrum antibiotics. 

Due to the diagnosis of NSTEMI and knowing the patient’s previous coronary anatomy, an urgent coronary angiogram was performed through a right femoral access. The angiogram showed a 70% stenosis of the mid left circumflex coronary artery, similar to the coronary angiogram 4 years prior. The RCA cannulation was challenging and a non-selective angiogram revealed a diffusely diseased RCA from the ostium to the distal RCA. The patient was also found to have an elevated left ventricular end-diastolic pressure of 30 mmHg. Percutaneous coronary intervention through a right femoral approach was planned for two days after intravenous diuresis in order to intervene in the culprit RCA with the anomalous take-off, and the patient was continued on the intravenous heparin drip. 

A 6 French (Fr) Amplatz left (AL) 1 guide catheter was used to engage the RCA. However, the engagement of the RCA and wiring with a Whisper .014-inch coronary guidewire (Abbott Vascular) was challenging, due to the anomalous take-off. We removed the guide catheter and coronary guidewire, and exchanged the 6 Fr Pinnacle TIF 10 cm groin sheath (Terumo) for a 6 Fr Brite 35 cm groin sheath (Cordis Corporation, A Cardinal Health company) to increase support and torque transmission. We attempted to cannulate the RCA with a 6 Fr AL2, a 6 Fr Judkins right (JR) 4, and finally, with a 6 Fr AL3 guide catheter, without success. We used a 5.5 Fr GuideLiner (Teleflex) through the 6 Fr AL1 guide catheter to engage the RCA via the mother-in-child technique, and wiring was performed successfully with a Prowater .014-inch coronary guidewire (Abbott Vascular) (Figure 2). A Sprinter Legend Rx 2.0 x 20 mm balloon (Medtronic) was advanced and we performed 4 sequential balloon predilatations in the proximal to distal RCA segments (Figures 3-4). A Resolute Onyx 2.25 x 38 mm stent (Medtronic) was deployed at 24 atmospheres (atm) in the mid to distal segments of the RCA with the assistance of the GuideLiner through “inchworming”1 (Figure 5). A second Resolute Onyx 2.25 x 34 mm stent was deployed at 26 atm in the proximal to mid segments, covering the previous stent (Figure 6). Due to the diffuse disease of the RCA, a Resolute Onyx 2.25 x 18 mm stent was deployed at 16 atm in the distal RCA, overlapping the initially deployed stent in the mid to distal RCA segments. The same stent balloon was used to inflate the interface of these two stents at 24 atm. There appeared to be another severe 70% stenosis in proximal RCA that was confirmed by a 30 frame-per-second angiogram. A 3.0 x 18 mm Xience stent (Abbott Vascular) was deployed at 24 atm in this segment with an excellent final result (Figures 7-8). The left circumflex artery stenosis was managed medically due to the small-caliber vessel. The patient was discharged on the following day. At his one-year follow-up visit, he continued to do well.


An anomalous origin of coronary arteries is uncommon and is associated with increased risk of atherosclerotic disease, angina, myocardial infarction, and sudden death, even in the absence of atherosclerosis.2,3 The anomalous origin of the RCA from the left aortic sinus of Valsalva is a rare congenital anomaly and is found in 0.15%-0.28% of coronary angiography cases, of which 0.06% cases undergo percutaneous coronary intervention (PCI).4,5

PCI equipment delivery in such cases can be challenging, due to variables including origin or anatomy of the vessel, lesion complexity, and the need for increased guide catheter support, all of which can contribute to procedural failure. Guide catheters may not sit well due to the anomalous take-off of the coronary artery. The guide catheter support needed for better delivery of equipment, including balloon and stents, can be facilitated with the use of several techniques, including use of larger or more supportive guide catheters, specialty shaped catheters (AL), deep guide catheter intubation of coronary arteries,6 increasingly supportive wires (such as the Prowater), one or more buddy wires,7 anchoring balloons,8 or guide catheter extension systems.

Knowing the anomalous RCA origin in our case, multiple conventional and specialized guide catheters (AL2, AL3, and JL 4) were used, all of which failed to cannulate the RCA due to its high origin, along with our lack of guide catheter support. Guide catheter torquability was facilitated by switching to a 6 Fr Brite 35 cm groin sheath, then a 5.5 Fr GuideLiner, along with use of an AL1 guide catheter for use of the mother-in-child technique, facilitating the engagement of the RCA and allowing for the successful delivery of balloons and stents. 

The Guideliner is a coaxial guide catheter extension that increases guide catheter support by allowing deep seating into the vessel9,10 and also provides useful coaxial alignment in cases where the coronary ostium take-off prevents the placement of a guiding catheter.9 Its use to facilitate the engagement of anomalous coronary arteries and coronary bypass grafts with unusual origins where conventional guide catheters have failed has been successfully demonstrated.11,12 Various studies10,12-17 have shown an increased procedural success rate with the use of a GuideLiner; however, procedural complications, including stent disruption or loss, vessel dissection, ventricular arrhythmia, and pressure damping, can occur. These complications can be further reduced with increased operator experience and the use of successive generations of the GuideLiner.13 

Our case reiterates the usefulness of GuideLiner along with the mother-in-child technique to facilitate the successful engagement and PCI of an anomalous coronary artery. 

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 Aditya Singh, MD, at

A commentary by Tim Fischell, MD can be read at:

Deep Intubation to Faciltate Coronary Intervention – Next Generation Guide Extension: The Edge of “No Edge”

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