Double Guiding Catheters for Complex Percutaneous Coronary Intervention

Abstract

A large-lumen guiding catheter is often used for complex percutaneous coronary intervention—particularly when a final kissing-balloon or 2-stent technique is required. However, catheter insertion is sometimes restricted by diseased vascular access sites or a tortuous vascular route.

We report 2 cases in which a unique double guiding catheter technique was used to create a lumen of sufficient size for complex percutaneous coronary intervention. In each patient, two 6F guiding catheters were used concurrently to engage the ostium of 1 target vessel. In 1 patient, these catheters were used for the delivery of 2 balloons to complete kissing-balloon dilation after single-stent placement. In the other patient, the catheters were used to deliver 2 stents sequentially to their respective target lesions. The stents were then deployed simultaneously as kissing stents, followed by high-pressure kissing-balloon postdilation.

The introduction of drug-eluting stents has greatly increased the use of percutaneous coronary intervention (PCI) for complex lesions and has markedly improved outcomes.^1–4 A large-lumen guiding catheter is often used for complex PCI, particularly when kissing-balloon dilation or a 2-stent technique is needed.⁵ Generally, the femoral artery is the preferred access site for PCI when a large-lumen guiding catheter is required. However, patients with coronary artery disease can also have peripheral arterial disease of the lower extremities or a tortuous aorta, which makes the femoral artery approach difficult or impossible. In these patients, the radial artery can be used as an alternative access site, but the smaller diameter of this vessel usually restricts the size of the guiding catheter that can be used. We describe our unique method of complex PCI as performed in 2 patients with the use of double guiding catheters.

Case Reports

Patient 1

In April 2009, a 67-year-old man presented at our institution with a 2-month history of chest tightness on exertion. Coronary angiography revealed chronic total occlusion of the distal left main coronary artery (LMCA) (Fig. 1A) with Rentrop grade 3 collateral vessels originating from the right coronary artery (RCA) and coursing to the left anterior descending coronary artery (LAD) and the left circumflex coronary artery (LCx) (Fig. 1B). Although coronary artery bypass grafting was strongly recommended, the patient chose not to undergo this procedure, and PCI was performed as an alternative treatment. Various guiding catheters—including a 7F extra back-up catheter 4.0 (EBU4) (Medtronic, Inc.; Minneapolis, Minn), a 7F Judkins left 4.0 (JL4) (Cordis Corporation, a Johnson & Johnson company; Miami Lakes, Fla), and a 7F Amplatz left 2.0 (AL2) (Cordis)—were tried via the right femoral approach, but the LMCA could not be engaged because of the extreme left lateral origin of the patient's LMCA from the left coronary cusp and the marked tortuosity of his descending aorta. Only a 6F JL 3.5 guiding catheter (Medtronic) was used successfully and gave adequate support for PCI. The 6F catheter was used because we did not have a 7F or 8F JL 3.5 catheter available in our catheterization laboratory at the time of the procedure.

Fig. 1 Patient 1. A) Left coronary angiography reveals chronic total occlusion of the distal left main coronary artery (LMCA). B) Right coronary angiography reveals Rentrop grade 3 collateral vessels from the right coronary artery to the left anterior descending and left circumflex coronary arteries. C) After stenting of the occluded LMCA, 6F JL 3.5 (Medtronic) (arrowheads) and 6F EBU 3.5 (Medtronic) (arrows) guiding catheters were used to engage the ostium of the LMCA to accommodate, respectively, a 4 × 12-mm and a 3 × 12-mm NC Sprinter® RX Noncompliant Balloon (Medtronic) for final kissing-balloon dilation. D) The final angiogram at the end of the kissing-balloon procedure.

After the guidewire crossed the chronic total occlusion and the lesion was adequately predilated, we deployed a 4 × 30-mm Endeavor® zotarolimus-eluting stent (Medtronic) to cover the lesion from the LMCA to the proximal LAD. We then attempted the final kissing-balloon dilation with 2 NC Sprinter® RX Noncompliant Balloons (Medtronic): a 4-mm for the LMCA–LAD lesion and a 3-mm for the LMCA–LCx lesion. However, the 6F guiding catheter could not accommodate both balloon catheters simultaneously. Therefore, we decided to use a 2nd guiding catheter (a 6F EBU 3.5; Medtronic) to engage the ostium of the LMCA through the patient's left radial artery. After slightly withdrawing the initial guiding catheter (tethered by the guidewire at the LAD) from the ostium of the LMCA, we inserted the 2nd guiding catheter to engage the ostium of the LMCA and to support the wiring of the LCx. We then used the 2 guiding catheters in turn to deliver the 4-mm and 3-mm NC Sprinter balloon catheters to the LAD and the LCx, respectively, in order to complete the kissing-balloon dilation (Figs. 1C and 1D).

Patient 2

In May 2009, a 68-year-old woman with diabetes mellitus and hypertension presented with angina on exertion, which she had experienced for 12 months. Coronary angiography revealed stenoses at the proximal LAD and the proximal LCx, with involvement of the ostia of both vessels (Fig. 2A). The patient's right coronary artery was diffusely diseased with a 90% stenosis over the mid portion. Because the patient's bilateral common femoral arteries were also found to be severely stenotic, the left radial artery was selected as the access site for PCI.

Fig. 2 Patient 2. A) Left coronary angiography reveals stenoses at the proximal left anterior descending coronary artery and the proximal left circumflex coronary artery. The ostia of both vessels are involved. B) After predilation, 6F EBU 3.5 (Medtronic) (arrows) and 6F JL 3.5 (Cordis) (arrowheads) guiding catheters were used to engage the ostium of the left main coronary artery and to accommodate, respectively, a 2.75 × 30-mm and a 3.5 × 30-mm Endeavor zotarolimus-eluting stent (Medtronic). C) The final angiogram at the end of the kissing-stent procedure.

The diameter of the patient's left radial artery was small, so we used a 6F EBU 3.5 guiding catheter (Medtronic), rather than a 7F one, to engage the ostium of the LMCA. We had planned to predilate the LAD and LCx lesions and then deploy kissing stents by simultaneously implanting a 2.75 × 30-mm Endeavor zotarolimus-eluting stent (Medtronic) into the LMCA–proximal LAD lesion and a 3.5 × 30-mm Endeavor zotarolimus-eluting stent into the LMCA–proximal LCx lesion. Our efforts were hampered, however, by the small lumen of the 6F guiding catheter. To overcome this problem, we introduced a 2nd guiding catheter (a 6F JL 3.5; Cordis) through the right radial artery to engage the ostium of the LMCA. Next, both zotarolimus-eluting stents were sequentially delivered to their respective target lesions through the 2 guiding catheters and were then deployed simultaneously. This kissing stenting was successful and was followed by high-pressure kissing-balloon postdilation (Figs. 2B and 2C).

Discussion

We used a novel double guiding catheter technique to facilitate complex PCI in 2 patients whose vasculature limited the use of larger-diameter guiding catheters. In both cases, a 2nd guiding catheter was introduced and provided additional space to accommodate the 2nd balloon catheter or 2nd stent for simultaneous balloon dilation or stenting, or both. Each tethered by different guidewires, the 2 guiding catheters were used to engage the same target vessel in turn by slightly withdrawing 1 catheter from the ostium and advancing the other into it. We believe that alternating the engagement of the catheters helped us avoid trauma to the target vessel and blockage of blood flow that could have occurred had the 2 guiding catheters been engaged simultaneously.

The femoral artery is the preferred access site for PCI when a larger guiding catheter is needed. However, this approach is contraindicated, for various reasons, in 2% to 10% of patients who require PCI.⁶ Although the brachial artery is an alternative access site for introducing a large-lumen guiding catheter, this approach has been associated with a 2.3% incidence of major, access site-related complications, such as severe local hematoma, brachial artery thrombosis, or pseudoaneurysm.⁷ In such cases, we believe that our double guiding catheter technique may provide a practical and safe solution to these complications with use of the radial arteries as bilateral access sites. Of note, loss of radial pulsation occurs in 3% of patients who undergo PCI with radial artery access; however, this loss is usually asymptomatic if patients are properly screened before the procedure.⁷

For patients in whom a small-lumen guiding catheter is used initially for PCI but a 2-stent or 2-balloon method is deemed necessary during the procedure, the double guiding catheter technique might also be a helpful alternative. Replacing the guiding catheter with one that has a larger lumen is customary in this situation. However, if predilating a lesion results in severe dissection, rewiring after replacing the guiding catheter might increase the risk of entering the false lumen. With the double guiding catheter technique, the original catheter and guidewire remain in position, and engagement with another guiding catheter ensures access to the true lumen and provides an additional route for the simultaneous delivery of 2 balloons or stents.