The catheter extension devices (GuideLiner [Teleflex], Guidezilla [Boston Scientific], and Telescope [Medtronic]) have significantly added to the armamentarium of complex percutaneous coronary intervention (PCI). Before these devices became available, larger size and more aggressively shaped guide catheters were used in cases requiring extra support, potentially increasing the risks of access site bleeding (bigger sheaths) or proximal coronary injury (“aggressive” shapes, deep intubations, larger caliber). Other options before extension catheters became available included stiffer guidewires, “buddy” wires, anchoring balloons, and, in more extreme cases, “armored” guide catheter techniques.1 In our experience, the guide extension catheters allow 6 French (Fr) guides for most PCIs to be comfortably successful, including chronic total occlusion PCIs.
We have experience in over 3,000 cases with extension catheters in PCI and peripheral interventions. We have used these catheters mostly for increased support to facilitate the equipment delivery into a coronary artery. However, we have also used these extenders for other applications, such as contrast preservation.2 It requires deep intubation with the extension catheter and then ultra-low contrast volume injections (1-2 cc) at low pressure (300 psi or less) and low velocity (1-2 cc/sec). These automatic injector settings can safely provide adequate opacification of practically any coronary segment for intervention, as long as the depth of intubation is sufficient. Other off-label applications of extension catheters include thrombectomy,3 removal of retained coronary equipment,4 guide catheter over-the-guidewire exchanges,5 and extending the length of the guide in order to reach the intervention area from remote access. When a longer guide is needed, the extension catheter can provide for extra reach. For example, one can extend a 110 cm (already “long”) Judkins right (JR) guide from radial access for renal artery intervention.6 Another relatively extreme application involves the two extension catheters telescopic technique (for example, a 6 Fr GuideLiner in an 8 Fr Guideliner with use of an 8 Fr guide).7 We find this “grandmother-mother-daughter” technique very powerful and versatile.
We present in this issue of Cath Lab Digest two cases of successful extension catheter use in challenging coronary anatomy. The first case involves an anomalous take-off right coronary artery requiring extra support for PCI with failed prior intervention. The second case is an acute coronary syndrome patient with unusually distal culprit lesion, requiring an extremely deep extension catheter intubation of the right coronary branch. While these cases might be relatively rare in everyday practice, we would like to share them as we think they illustrate well the added value that extension catheters bring to the world of complex PCI. Extension catheters and their associated techniques have revolutionized complex PCI.
Read the two cases in this series:
Case #1: A Deep Dive With a Guide Catheter Extension in a Severely Calcified Tortuous Right Coronary Artery in Non-STEMI
Case #2: The Need for a Guide Catheter Extension: Percutaneous Coronary Intervention of a Diffusely Diseased Anomalous Right Coronary Artery
- Stys AT, Lawson W, Brown D. Extreme coronary guide catheter support: a case of a novel telescopic guide catheter system with a contralateral aortic wall support. J Invasive Cardiol. 2007; 19(4): E107-E110.
- Tunuguntla A, Daneault B, Kirtane AJ. Novel use of the GuideLiner catheter to minimize contrast use during PCI in a patient with chronic kidney disease. Catheter Cardiovasc Interv. 2012; 80(3): 453-455. doi: 10.1002/ccd.23331.
- Stys AT, Stys TP, Rajpurohit N, Khan MA. A novel application of GuideLiner catheter for thrombectomy in acute myocardial infarction: a case series. J Invasive Cardiol. 2013; 25(11): 620-624.
- Warisawa T, Mitarai T, Doi S, et al. Novel use of GuideLiner with a low-profile balloon for the retrieval of disrupted balloon catheter. Int Heart J. 2018; 59(6): 1454-1457. doi:10.1536/ihj.17-646.
- Stys TP, Khan MA, Rajpurohit N, Stys AT. A new technique for coronary guide catheter exchange over coronary guidewire using GuideLiner catheter. J Invasive Cardiol. 2014; 26(5): E56-E58.
- Gedela M, Li S, Stys T, Stys A. A novel technique of stenting of the renal artery in-stent restenosis with GuideLiner® through radial approach. Case Rep Vasc Med. 2017; 2017: 1742058. doi:10.1155/2017/1742058.
- Stys AT, Khan MA, Rajpurohit N, Stys TP. Novel extreme triple telescopic support for percutaneous coronary intervention. Cath Lab Digest. 2017; 25(3): 30-33. Available online at https://www.cathlabdigest.com/article/Novel-Extreme-Triple-Telescopic-Support-Percutaneous-Coronary-Intervention. Accessed September 15, 2020.