Novel triple coaxial system to navigate 9 French balloon guiding catheter into common carotid artery

Abstract

Background

It is often hard to navigate a 9 French (F) balloon guiding catheter in patients with type III or bovine aortic arch. Also, a common carotid artery stenosis is challenging, because a guidewire cannot be advanced distally. We developed the combination of a 4F Simmons-type catheter and a 6F distal access catheter as a coaxial inner catheter to navigate a 9F balloon guiding catheter to overcome these difficulties.

Materials and methods

Medical record at our institution was retrospectively reviewed and carotid artery stenting cases in which the 4F Simmons-6F distal access catheter system was employed as a coaxial catheter to navigate a 9F balloon guiding catheter were identified. To construct this system, a 4F 145 cm SY3 (Hanako Medical, Saitama, Japan) and a 6F 118 cm Cerulean DD6 (Medikit Co. Ltd., Tokyo, Japan) were usually employed. A rotating hemostatic valve should be as short as possible and was attached to only a 9F balloon guiding catheter. The length of a 0.035-in. guidewire needed to be 180 cm or longer.

Results

During the study period, 106 carotid artery stenting cases were identified. Of these, this system was employed in 29 cases that included 5 cases with a steno-occlusive lesion at common carotid artery/external carotid artery, 10 with type III or bovine arch, and 11 harboring both. In all the cases, a 9F balloon guiding catheter was successfully navigated.

Conclusion

The 4F Simmons-6F distal access catheter system was useful in navigating a 9F balloon guiding catheter in patients with a common carotid artery stenosis, an external carotid artery occlusion, and an in-stent restenosis, especially when they also harbored type III or bovine aortic arch.

Introduction

In endovascular treatments, the first key step is to navigate a guiding catheter (GC) to the appropriate position. It is, however, often hard to navigate large profile GCs or balloon GCs (BGCs)¹ in cases with type III aortic arch or bovine aortic arch.^2–5 Simmons-type catheters are one of the solutions to overcome such aortic arch, and 6 French (F) Simmons-type catheters are generally employed as a coaxial inner catheter to navigate 9F BGCs.^1,6,7

Besides the aortic arch anatomy, a steno-occlusive lesion at the common carotid artery (CCA), which is often observed in patients with Takayasu vasculitis⁸ or radiation-induced carotid stenosis,⁹ is also challenging to navigate GCs, because a guidewire and the following inner catheter cannot be advanced distally, and few studies have focused on how to overcome such lesions.

In this article, we propose a triple coaxial system, the 4F Simmons-6F distal access catheter (DAC) system (the combination of a 4F Simmons-type catheter and a 6F DAC) to navigate 9F BGCs in patients with such difficulties.

Materials and methods

The protocol of this study was approved by our Institutional Review Board.

In our institution, all the carotid artery stenting (CAS) was performed under the double protection system^10,11 to prevent thromboembolic complications using a filter protection device and either a MOMA ultra (Medtronic, Minneapolis, MN) or a 9F BGC along with a Carotid GuardWire PS (Medtronic, Minneapolis, MN). The 4F Simmons-6F DAC system was introduced on September 2013, and since then, 106 CAS had been performed until December 2019 using a 9F BGC. Among the 106 cases, the 4F Simmons-6F DAC system was employed in 29 cases for the following reasons: (1) navigation of a 9F BGC was considered hard based on the preoperative evaluation and (2) the initial inner catheter failed to navigate a 9F BGC.

Construction of the 4F Simmons-6F DAC system

To establish the 4F Simmons-6F DAC system, a 4F 145 cm SY3 (Hanako Medical, Saitama, Japan) and a 6F 118 cm Cerulean DD6 (Medikit Co. Ltd., Tokyo, Japan) were usually employed because of their suitable length to navigate a 9F BGC whose length is 90 cm (Figure 1). A rotating hemostatic valve attached to the 9F BGC should be as short as possible, and no hemostatic valve was attached to the 6F DAC. The length of a 0.035-in. guidewire needed to be 180 cm or longer.

Figure 1.

The 4F Simmons-6F DAC system for navigation of a 9F BGC. Note that the length of the 6F DAC and the 4F Simmons-type catheter need to be long enough to work as inner catheters. To preserve this working length, an RHV is attached to only the 9F BCG while nothing is attached to the 6F DAC and the 4F catheter (upper left circle). The RHV needs to be as short as possible.

BGC: balloon guiding catheter; DAC: distal access catheter; F: French; RHV: rotating hemostatic valve.

Navigation of a 9F BGC using the 4F Simmons-6F DAC system

After insertion of a 9F sheath into the common femoral artery, systemic heparinization was performed to maintain activated clotting time over 250 s. A 9F BGC was introduced to thoracic descending aorta, and a target vessel (the brachiocephalic or the left CCA) was selected using a 4F Simmons-type catheter (Figure 2(a)). A 0.035-in. guidewire was then advanced as distal as possible to the external carotid artery (ECA). In case there was a stenotic lesion at the CCA, the guidewire stayed just proximal to the stenosis. The guidewire was then followed by the 4F catheter. In case the 4F catheter was about to fall into the ascending aorta in advancing the guidewire distally, position of the 6F DAC and/or the 9F BGC was tweaked to support the 4F catheter (Figure 2(b) to (d)). Then, the 6F DAC followed the 4F catheter, and at this step, the 6F DAC needed to be advanced as distal as possible, so that the tip of the 6F DAC caught up the tip of the 4F catheter (Figure 2(e)). Finally, the 9F BGC was navigated to the CCA (Figure 2(f)). In all the steps, care must be taken for catheters not to fall into the ascending aorta. In case that it was hard to advance the 6F DAC or the 9F BGC, the use of stiffer guidewires was helpful.

Figure 2.

How to navigate a 9F BGC using the 4F Simmons-6F DAC: (a) a target vessel is selected by the 4F Simmons-type catheter; (b) if the 4F catheter is falling down into the ascending aorta in advancing a 0.035-in. guidewire distally, the 6F DAC is advanced to support the 4F catheter; (c) the 9F BGC is also advanced to the orifice of the target vessel; (d) the 4F catheter can be advanced in this situation; (e) the 6F DAC is advanced until the tip of the 6F DAC catches up the tip of the 4F catheter; (f) the 9F BGC finally advanced to the target vessel. Note that during the navigation of the 9F BGC, the tip of the guidewire remains the CCA, and it is not necessarily advanced to the distal ECA.

BGC: balloon guiding catheter; CCA: common carotid artery; DAC: distal access catheter; ECA: external carotid artery; F: French.

Figure 3.

An illustrative case of a 71-year-old man with the right CCA stenosis: (a) digital subtraction angiography demonstrates a severe stenosis of the right CCA (black arrow) due to the previous radiation therapy for his pharyngeal cancer; (b) a 0.035-in. guidewire is advanced just proximal to the narrowest lumen, which is followed by a 4F Simmons-type catheter (black arrowhead); (c) a 6F DAC (white arrowhead) was then advanced to support the 4F catheter (black arrowhead); (d) a 9F BGC (white arrow) was advanced to support the preceding catheters and then, the 4F catheter was further advanced (black arrowhead); (e) the 6F DAC (white arrowhead) was also advanced to catch up the 4F catheter; (f) the 9F BGC (white arrow) was finally navigated to the target CCA. Note that the tip of the guidewire was kept proximal to the narrowest lumen all through the procedure.

BGC: balloon guiding catheter; CCA: common carotid artery; DAC: distal access catheter; F: French.

Results

In 27 of the 29 cases in whom CAS was performed using the 4F Simmons-6F DAC system to navigate a 9F BGC, the system was employed as the initial inner catheter. The 27 cases included 17 cases (58.6%) with a steno-occlusive lesion either at the CCA or at the ECA: 12 cases with a CCA stenosis, 2 cases with an in-stent restenosis, and another 2 cases with an ECA occlusion. The 17 cases included eight cases harboring type III aortic arch and three cases harboring bovine aortic arch. Of the other 12 cases without the CCA/ECA lesion but the 4F Simmons-6F DAC system was initially employed, seven cases harbored type III aortic arch and one case had bovine arch. In the remaining two of the 29 cases, the 4F Simmons-6F DAC system was employed as the second inner catheter, because the initial 4-5-6F JB2-type catheter failed to navigate a 9F BGC due to type III aortic arch. Thus, the 4F Simmons-6F DAC system overcame 4 cases with a steno-occlusive lesion either at the CCA or at the ECA, 10 cases with type III or bovine aortic arch, and 11 cases harboring both (Table 1).

Table 1.

CAS cases using the 4F Simmons-6F DAC system.

Case	Age	Gender	Side	Aortic arch	CCA/ECA lesion	Initial inner catheter	Second inner catheter	Initial GW	Second GW
1	79	M	L	Type III	CCA stenosis	4F Simmons-6F DAC		RF	Amplatz
2	66	M	L	Type III		4F Simmons-6F DAC		RF	RF half stiff
3	64	M	L	Type III	CCA stenosis	4F Simmons-6F DAC		RF
4	72	M	L	Type III	CCA stenosis	4F Simmons-6F DAC		RF
5	77	F	L	Type III		4F Simmons-6F DAC		RF	RF half stiff
6	80	M	L	Type III		4F Simmons-6F DAC		RF
7	74	M	R	Type III	CCA stenosis	4F Simmons-6F DAC		RF
8	74	M	R	Type III	in-stent restenosis	4F Simmons-6F DAC		RF
9	69	M	L	Type III	CCA stenosis	4F Simmons-6F DAC		RF
10	68	M	L	Type III	in-stent restenosis	4F Simmons-6F DAC		RF half stiff
11	60	M	L	Type III		4F Simmons-6F DAC		RF	RF half stiff
12	88	M	R	Type III		4F Simmons-6F DAC		RF
13	77	M	R	Type III		4F Simmons-6F DAC		RF
14	72	F	L	Type II	CCA stenosis	4F Simmons-6F DAC		RF
15	71	M	R	Bovine	CCA stenosis	4F Simmons-6F DAC		RF	RF half stiff
16	72	M	L	Bovine	CCA stenosis	4F Simmons-6F DAC		RF	RF half stiff
17	59	M	L	Type I	CCA stenosis	4F Simmons-6F DAC		RF
18	80	F	L	Bovine	ECA occlusion	4F Simmons-6F DAC		RF half stiff
19	63	M	L	Bovine		4F Simmons-6F DAC		RF
20	80	M	R	Type III		4-5-6F JB2	4F Simmons-6F DAC	RF	RF half stiff
21	63	M	L	Type III		4-5-6F JB2	4F Simmons-6F DAC	RF
22	79	M	L	Type Ia		4F Simmons-6F DAC		RF
23	80	M	L	Type III		4F Simmons-6F DAC		RF	RF half stiff
24	73	M	R	Type II	CCA stenosis	4F Simmons-6F DAC		RF
25	61	M	R	Type III	CCA stenosis	4F Simmons-6F DAC		RF
26	67	M	R	Type IIb		4F Simmons-6F DAC		RF
27	82	M	L	Type I	CCA stenosis	4F Simmons-6F DAC		RF
28	72	M	L	Type IIb	ECA occlusion	4F Simmons-6F DAC		RF	RF half stiff
29	74	M	L	Type II		4F Simmons-6F DAC		RF

^aThe orifice of the innominate artery and that of the L CCA was close.

^bThe vertical distance from the origin of the innominate artery to the top of the arch was almost two left CCA diameters.

CAS: carotid artery stenting; CCA: common carotid artery; DAC: distal access catheter; ECA: external carotid artery; GW: guide wire; L: left; R: right; RF: 0.035-in. radifocus.

RF: Terumo, Tokyo, Japan; Amplatz: Cook Medical, Bloomington, IN, USA.

Of the 29 cases in whom the 4F Simmons-6F DAC system was employed, a half stiff wire was needed to navigate a 9F BGC in 10 cases, and an Amplatz extra-stiff wire (Cook Medical, Bloomington, IN) was needed in one case; nevertheless, in all the 29 cases, a 9Fr BGC was successfully navigated using this system.

Illustrative cases

Case 15

A 71-year-old male was found to harbor a stenotic lesion at his right CCA when cervical-enhanced CT was taken to follow up the postoperative course of a pharyngeal cancer. The cancer had been surgically resected, and radiation therapy had been added when he was 43 years old. Since the CCA stenosis was severe and likely radiation-induced (Figure 3(a)), CAS was planned. Because of the CCA stenosis and the bovine aortic arch, the 4F Simmons-6F DAC system was employed as the initial inner catheter. In navigating a 9F BGC, a 0.035-in. guidewire was kept just proximal to the plaque in the CCA where the 4F catheter was advanced (Figure 3(b) and (d)), followed by the 6F DAC (Figure 3(c) and (e)). The 9F BGC was then advanced to the CCA successfully (Figure 3(f)). No additional technique was required to advance the 9F BGC, and CAS was completed.

Discussion

We replaced the existing Simmons-type catheters, which are usually employed to overcome type III or bovine aortic arch, with the combination of a 4F Simmons-type catheter and a 6F DAC because of several advantages. First, compared with the 6F Simmons-type catheter, its 4F tip yields less gap against a 0.035-in. guidewire, which provides better trackability. Additionally, the 4F tip may bring better selectivity of target vessels compared with the 6F tip because of its flexibility. Second, in the 4F Simmons-6F DAC system, a 4F and a 6F catheters in addition to a 9F BGC can move independently. This enables us to advance each catheter by turns and gradually, which minimizes the risk that the catheters fall down into the ascending aorta. Third, in this system, once a 4F catheter is advanced, the following 6F DAC can entirely cover the 4F catheter. This makes an “entire 6F pathway” for the following 9F BGC, which makes gaps free and provides less ledge effect all the way. In contrast, in 4-5-6F Simmons-type catheters, because the tip of the catheters consists of a 9 cm of 4F part and a 4 cm of 5F part, a 9F BGC has to clear the total 13 cm of “gap-segment” in following the inner catheters.

In navigating of a 9F BGC in CAS, patients to whom these advantages are the most beneficial seem to be those with a CCA stenosis, an ECA occlusion, or an in-stent restenosis. This is because, in these cases, a guidewire and the following inner catheter cannot be advanced to the distal ECA, but can be advanced to the proximal CCA at the most: in cases of the 6F catheters, a larger gap between the 6F tip and the guidewire would prevent the 6F catheter from following the guidewire, while in the 4F Simmons-6F DAC system, the 4F and then the 6F catheter can follow the guidewire without any gap: in cases of the 4-5-6F catheters, the following 9F BGC has to pass a 5F and a 4F parts to go there, while in cases of the 4F Simmons-6F DAC system, the 9F BGC should pass a 6F axis. In our series, a 9F BGC was successfully navigated using the 4F Simmons-6F DAC system in all the patients with a CCA stenosis, an ECA occlusion, or an in-stent restenosis.

The 4F Simmons-6F DAC system was also useful for type III and bovine aortic arch; although in this series, its superiority to the existing 6F or 4-5-6F Simmons-type catheters was not proven. The 4F Simmons-6F DAC system cleared the 21 type III or bovine aortic arches without any failure. Moreover, 11 of the 21 type III or bovine arches accompanied the steno-occlusive lesion at the CCA or the ECA.

Neither the type III/bovine arch nor the CCA/ECA steno-occlusive lesion was observed in three cases. For one case with type I aortic arch without the CCA/ECA lesion, the preoperative CT demonstrated that the orifice of the left CCA was close to that of the innominate artery. Therefore, the operator treated this as bovine arch and, thus, chose the 4F Simmons-6F DAC system as the initial inner catheter. For two cases with type II aortic arch without the CCA/ECA lesion, the vertical distance from the origin of the innominate artery to the top of the arch was almost two left CCA diameters.⁴ The operators therefore treated these arches as type III and chose the 4F Simmons-6F DAC system as the initial inner catheter.

To establish the 4F Simmons-6F DAC system, the length of the inner catheters needs to be considered. Given the length of a 9F BGC is 90 cm, a 6F inner catheter needs to be longer than at least 110 cm considering the length of a rotating hemostatic valve connected to the 9F BGC. Besides the Cerulean DD6, various 6F DACs would be also applicable to this system as far as the length is suitable. The Cerulean DD6, however, seems the only DAC usable in our country because of several “social limitations” such as insurance problems. Similarly, a 4F Simmons-type catheter needs to be longer than at least 130 cm in order to preserve the Simmons-shaped segment that is essential to select target vessels, and thus, most of conventional diagnostic 4F Simmons-type catheters are too short for this purpose. At the time of writing this paper, the only 4F catheter that meets this purpose and is available in Japan is the SY3 145 cm. Therefore, the combination of the 6F 118 cm Cerulean DD6 and the 4F 145 cm SY3 is exquisite to establish the 4F Simmons-6F DAC system to navigate the 9Fr 90 cm BGC.

Besides 9F BGCs, the 4F Simmons-6F DAC system can also navigate 6F guiding sheaths or 8F GCs. Therefore, it is also applicable to other various endovascular treatments such as coil embolization for intracranial aneurysms using adjunctive technique,¹² deployment of the pipeline embolization device for large/giant carotid aneurysms,¹³ or mechanical thrombectomy for acute ischemic stroke.¹⁴

Conclusion

The 4F Simmons-6F DAC system is a useful alternative to the existing coaxial catheters to navigate a 9F BGC. This system was beneficial in patients with a CCA stenosis, an ECA occlusion, and an in-stent restenosis, especially when they also harbored type III or bovine aortic arch.