Successful percutaneous coronary intervention using an inverted Amplatz left type guiding catheter for cannulation into an acutely angled saphenous vein graft: A case report

Abstract

Successful percutaneous coronary intervention (PCI) requires selecting an appropriate guiding catheter to ensure adequate back-up support and optimal visualization. PCI for saphenous vein grafts (SVGs) is particularly challenging because of factors such as acute angulation at the anastomosis and severe stenosis. We herein describe a novel approach utilizing an inverted Amplatz left (AL)-1.0 guiding catheter to achieve coaxial alignment in a patient with an acute SVG-to-aorta angle and significant stenosis at the SVG entry site. The patient, a man in his mid-60s with a history of coronary artery disease, had undergone multiple PCI procedures and coronary artery bypass grafting, including SVG to the right coronary artery. He presented with unstable angina caused by severe stenosis at the SVG anastomosis. Standard Judkins right-4.0 and AL-1.0 catheters failed to achieve the coaxial alignment necessary for adequate back-up support. However, by inverting the AL-1.0 catheter, coaxial alignment was successfully achieved, enabling PCI with stent deployment. This inverted AL catheter technique is a simple, cost-effective method for addressing complex SVG PCI cases and may expand the options available for managing challenging PCI procedures.

Learning objective

Achieving coaxial alignment with standard guiding catheter manipulation during percutaneous coronary intervention for a saphenous vein graft (SVG) can be challenging. In our case, inverting the Amplatz left guiding catheter allowed precise coaxial alignment with the SVG, enabling successful treatment in a complex scenario. This simple, cost-effective, and practical technique offers a valuable option for percutaneous coronary intervention in SVGs with sharp aortic branching angles.

Introduction

Successful percutaneous coronary intervention (PCI) requires the selection of appropriate guiding catheters to ensure adequate back-up support and optimal visualization. This is particularly challenging in PCI for saphenous vein grafts (SVGs) because of factors such as the geometry of the anastomosis site and the angulation between the graft and the ascending aorta. These anatomical complexities can hinder guiding catheter cannulation and back-up support, making the procedure technically demanding [1,2]. We herein describe a novel technique that was successfully employed in a patient with an acute anastomosis angle between the SVG and the aorta, along with severe stenosis at the SVG entry site, where standard guiding catheters were ineffective.

Case report

The patient was a man in his mid-60s with chronic renal failure due to polycystic kidney disease who had been on hemodialysis since 2019. He developed angina in 2020 and underwent his first PCI on the mid right coronary artery (RCA). Since then, he had experienced recurrent restenosis and the development of new stenotic lesions, with a history of five PCI procedures on the RCA by the end of 2021.

In March 2022, he presented with unstable angina. Coronary angiography at that time revealed multiple RCA restenoses (Fig. 1A) and a newly developed severe stenosis in the proximal left anterior descending artery (LAD), leading to an elective coronary artery bypass grafting procedure. The bypass involved anastomosing the left internal mammary artery to the LAD and sequentially connecting an SVG to the RCA at the posterior descending artery and posterolateral branch. Postoperative multi-detector computed tomography (CT) angiography confirmed good graft patency. The SVG was anastomosed to the right side of the ascending aorta at an inferior position, forming an acute angle with the aortic wall (Fig. 1B and C). Following coronary artery bypass grafting, the patient's symptoms stabilized.

Fig. 1.

Preoperative coronary angiography and postoperative computed tomography angiography. (A) Coronary angiography shows severe and multiple stenoses in the RCA (red arrowheads). (B and C) Postoperative volume-rendered three-dimensional images from computed tomography angiography demonstrate good patency of the SVG anastomosed from the aorta (yellow arrowheads) to the RCA (white arrowheads). Note that the SVG is anastomosed at an inferior position of the ascending aorta, forming an acute angle with the aortic wall.

RCA, right coronary artery; SVG, saphenous vein graft; Ao, ascending aorta; LIMA, left internal mammary artery; LAO, left anterior oblique view; RAO, right anterior oblique view; CAU, caudal view; CRA, cranial view.

In March 2023, he was hospitalized for a urinary tract infection and developed intermittent chest pain. His electrocardiogram revealed ST depression in the inferior and lateral leads, although his serum creatine kinase and troponin T levels remained within normal ranges. He was diagnosed with unstable angina and underwent emergency coronary angiography, which identified a 99 % stenosis at the SVG–aortic anastomosis as the culprit lesion (Fig. 2A). The native RCA had severe tandem stenoses (Fig. 2B) and the left internal mammary artery–LAD bypass was patent. PCI for the native RCA was considered unsuitable for ad-hoc intervention. Therefore, we determined to perform ad-hoc PCI on the SVG for rapid relief of the patient's symptom.

Fig. 2.

Angiography, cannulation of the guiding catheter, and wire-crossing procedure for SVG intervention. (A) Preprocedural angiography of the SVG reveals a severely narrowed segment (red arrowheads) extending from the aorto–SVG anastomosis site (yellow arrowheads) to the proximal SVG. Note the acute angle formed between the SVG outline (yellow dotted line) and the aortic wall (white dotted line). (B) Angiography of the native right coronary artery reveals severe multiple stenoses (white arrowheads), which are considered unsuitable for ad-hoc intervention. (C) The JR-4.0 guiding catheter and (D) the AL-1.0 guiding catheter both failed to achieve coaxial alignment with the SVG, preventing guidewire passage through the stenotic lesion. (E) By inserting a 0.035-inch guidewire and inverting the AL-1.0 guiding catheter, coaxial alignment with the SVG was achieved, allowing a 0.014-inch guidewire to successfully cross the stenotic lesion.

SVG, saphenous vein graft; Ao, ascending aorta; JR, Judkins right; AL, Amplatz left; LAO, left anterior oblique view.

Emergency PCI was performed via the femoral approach with a 6-French system. Initial angiography of the SVG using a Judkins right (JR)-4.0 diagnostic catheter was successful, but attempts to advance a 0.014-inch PCI guidewire (SION blue; Asahi Intecc, Aichi, Japan) through a 6-French JR-4.0 guiding catheter (Heartrail II; Terumo, Tokyo, Japan) failed because of inadequate back-up support, leading to catheter disengagement (Fig. 2C). Similar results occurred with a 6-French Amplatz left (AL)-1.0 guiding catheter (Heartrail II; Terumo), which could not achieve coaxial alignment with the SVG (Fig. 2D).

When attempts to pass the guidewire through the narrowed segment of the SVG failed, the catheter became dislodged, preventing further progress. A different technique was then required. Taking the postoperative CT angiography findings into account, we considered switching from the AL-1 guiding catheter to another type, such as a multipurpose or Ikari-left catheter. However, when we inserted a 0.035-inch guidewire (Radifocus; Terumo) into the AL-1 catheter and pulled it back, we coincidentally found that the tip of the inverted AL-1 catheter aligned coaxially with the SVG entry. Keeping the 0.035-inch guidewire in place, the guiding catheter was advanced toward the SVG entry. Contrast injection confirmed rapid opacification of the SVG with stable coaxial alignment.

We then advanced a 0.014-inch PCI guidewire (SION blue) alongside the 0.035-inch wire, which crossed the lesion smoothly (Fig. 2E). After successfully positioning the SION blue wire distally within the graft, the 0.035-inch guidewire was removed, and a second 0.014-inch PCI guidewire (MINAMO; Asahi Intecc) was advanced across the SVG stenosis, maintaining stable catheter positioning. This allowed the PCI to proceed without complications.

After predilation with a 2.0 × 15 mm balloon (Ryurei; Terumo), intravascular ultrasound revealed extensive attenuated plaque within the SVG (Fig. 3A–C). Using distal embolic protection (Filtrap; Nipro, Osaka, Japan), a 4.0 × 28 mm drug-eluting stent (Xience Skypoint; Abbott Vascular, Santa Clara, CA, USA) was deployed from the SVG anastomosis to the proximal segment, followed by post-dilation with a 4.5 × 12 mm balloon (Hiryu Plus; Terumo). Post-PCI intravascular ultrasound and angiography confirmed satisfactory stent expansion (Fig. 3D–F). The procedure concluded uneventfully, and the patient was discharged without adverse events.

Fig. 3.

Successful stent implantation for SVG stenosis. (A) Pre-stenting angiography demonstrates severe narrowing from the aorto–SVG anastomosis site (yellow arrowheads) to the proximal SVG. (B and C) Intravascular ultrasound images of the cross-sectional area indicated in panel A show an extensive plaque burden. (D) Post-stenting angiography confirms satisfactory vessel expansion. (E and F) Intravascular ultrasound images of the cross-sectional area indicated in panel D demonstrate good stent expansion and apposition from the aorto-SVG anastomosis site (yellow arrowheads in panel D) to the proximal SVG. (G) Schema illustrating the inverted AL technique. Inverting the AL guiding catheter achieves coaxial alignment with the SVG, enabling successful PCI.

SVG, saphenous vein graft; Ao, ascending aorta; AL, Amplatz left; LAO, left anterior oblique view.

Discussion

Selecting a guiding catheter with an appropriate shape is critical for successful PCI, particularly in cases involving anomalous coronary artery origins or SVGs [1,3]. Suboptimal cannulation or insufficient back-up support can prolong procedures, increase radiation exposure, and elevate the risks of contrast agent usage and complications. For PCI on SVGs, it is essential to consider factors such as ascending aorta diameter, anastomosis location, and the aorto–SVG branching angle [4]. JR and AL catheters are commonly used for SVGs to the RCA, with AL catheter preferred in dilated aortic roots. If the SVG has an inferior take-off with acute angle, a multipurpose catheter is useful for cannulating and maintaining coaxiality. Ikari-left or hockey stick catheters may also be effective in some cases [5].

In this case, the aorto–SVG angle was sharp, and there was severe stenosis at the anastomosis site. When we attempted to engage the SVG entry using JR-4 or AL-1 guiding catheters in their standard configurations, we could not achieve coaxial alignment or adequate back-up support. As the next step, we considered switching to a multipurpose catheter for better coaxial alignment with the SVG, or to an Ikari-left catheter, which can provide strong back-up support due to its unique shape [6]. However, upon inverting the AL-1 catheter, we coincidentally found its tip aligned coaxially with the SVG (Fig. 3G). This inverted configuration enabled us to successfully complete the complex PCI, including catheter insertion, guidewire passage, and stent placement under distal protection, without any complications.

For PCIs involving SVGs with sharp anastomosis angles, multipurpose catheters with less tip curvature can provide better coaxial alignment [5]. Additionally, although the inverted AL-1 technique used in this case was discovered coincidentally, it may be useful in other cases where the SVG anastomosis is located inferiorly with an acute angle. This technique via the femoral approach may also be applicable for the left radial approach, since the catheter path and manipulation are similar. However, the right radial approach differs significantly in catheter direction and handling [7], so it is unclear if this technique can be used in that setting. Further case accumulation is needed to evaluate its feasibility. When no suitable guiding catheter shape is available, heating the catheter tip with a hairdryer and manually reshaping it can be an option [8]. Both the inverted AL catheter method used in this case and the manual reshaping technique are simple, cost-effective, and practical solutions that do not require additional devices.

In this patient, postoperative CT angiography had already provided a clear visualization of the SVG anatomy before the procedure. If we had analyzed the patient's angio-CT images in greater detail prior to the PCI, we might have been able to select the appropriate guiding catheter more quickly. For patients with bypass grafts using SVGs or abnormal native coronary artery origins, pre-procedure angio-CT imaging can help identify vascular pathways. Sharing this information with the catheterization laboratory team may facilitate planning the guiding catheter selection and strategy, potentially enabling quicker and more effective PCI for challenging cases.

PCI for SVGs as the culprit vessel in the setting of acute coronary syndrome is usually feasible. However, PCI for SVGs carries a high risk of the no-reflow phenomenon [9]. Moreover, even when successful, restenosis rates are reported to be high, and cardiovascular outcomes are generally worse than those of PCI for native coronary arteries [10]. Therefore, in this case, regular monitoring of SVG patency using contrast-enhanced CT or invasive angiography, along with early intervention in the event of restenosis, will be necessary. In such situations, the inverted AL-1 technique described in this report may be useful.

Conclusion

Inverting the AL-1 guiding catheter is a straightforward and cost-effective technique for achieving coaxial alignment in challenging SVG PCI cases. This approach provides a practical solution for operators dealing with acute SVG anastomosis angles, streamlining the procedure and enhancing the likelihood of success.

Patient consent

The patient provided informed consent for publication of this case report.

Funding

None.

Declaration of competing interest

The authors declare that there is no conflict of interest.