The long wire technique--a new technique for steerable balloon catheter dilatation of coronary artery stenoses

A new technique for steerable balloon dilatation is described.In contrast to the usual procedure the stenosis is first crossedby a long wire only. To minimize injury of the vessel wall thewire is equipped with a thickened ball-shaped tip. After thestenosis has been crossed and the wire tip has been advancedfar enough, the balloon catheter is intserted over the longwire. If necessary, the balloon catheter can be removed andanother one can be inserted without repeat crossing. If an occlusionis caused by the process of dilatation a perfusion cathetercan be advanced distal to the occlusion. Perfusion can be performedby help of a simple syringe-tap system because the cross sectionalarea of this catheter is much larger than a single lumen ofthe double lumen balloon catheter. This procedure even allows the dilatation of branching stenosesthrough the same guiding catheter whereas for the usually performed‘kissing balloon’ technique two guiding cathetersare required. Preliminary experience with 80 patients has shown that crossingof stenoses is facilitated by the new technique because steeringof the guide wire and display by contrast medium injectionsare unhindered. If required, the balloon catheter can be changedfor another one without difficulty. In case of occlusion, thelesion can be crossed again without any risk and repeat dilatationor coronary perfusion can be performed.     

First clinical experience of a novel penetration catheter for patients with severe coronary artery stenosis.

The study aimed to evaluate the efficacy of a novel penetration catheter for severe coronary artery disease. Severe coronary artery diseases such as chronic total occlusions or severe calcified stenoses sometimes obstruct the subsequent crossing of balloon catheter after successful wire crossing. A novel penetration over-the-wire catheter has been developed for severe coronary artery disease. The main shaft is a coreless stainless coil that consists of eight stranded stainless wires to cross through a severe stenosis by manual rotation. This device was applied during percutaneous coronary intervention for patients with severe coronary artery disease obstructing the subsequent crossing of balloon or microcatheters after successful wire crossing. Initial results were examined. Fourteen eligible patients were enrolled consecutively. Among those, 10 patients had chronic total occlusion and 7 patients showed severe angiographical calcification. The device was successfully crossed through the lesion and enabled subsequent dilatation in all patients without any complication. This new device enables the crossing of severe coronary artery stenoses and therefore favors further dilatation in this lesion subset.     

Angioplasty of total coronary occlusions using combination of intracoronary Probing Catheter and balloon on wire Probe.

We describe our experience with a technique for PTCA of total coronary occlusions using the ultra low profile balloon on wire Probe. An intracoronary Probing Catheter was used to facilitate crossing the stenosis with a guide wire. This was followed by exchanging the guide wire for the Probe into the obstruction for balloon dilatation. This technique was used in 22 consecutive patients undergoing PTCA for chronic total occlusion. The total obstruction could be crossed by guide wire (0.014 flex or 0.016 standard) passed through Probing Catheter in 19 patients (86%). The obstruction could be successfully dilated by the Probe, delivered through the probing catheter, in 17 of these patients. Of the remaining 2 patients, one could be dilated by sequential dilatation using over the wire low profile balloon system and the other one by dilatation with the Probe, respectively. The Probing Catheter technique offers a new method to apply balloon on wire technology to the dilatation of chronic total coronary occlusions with very promising results.     

Successful retrograde treatment of a mid left anterior descending artery chronic total occlusion using a novel “guide parallel to wire” technique

Antegrade crossing of a chronic total occlusion adjacent to a large side branch may fail. We describe a patient in whom a chronic total occlusion of the proximal left anterior descending artery was successfully crossed retrogradely through an apical collateral after a failed antegrade crossing attempt. No balloon was long enough to reach the left anterior descending artery lesion retrogradely. A retrograde Whisper wire was snared though an antegrade left main guide catheter introduced via the radial approach. We were unable to retrieve the wire via the radial guide catheter because of wire fracture during withdrawal. Externalization of the retrograde guidewire required use of a Frontrunner catheter and removal of the antegrade guide catheter. The lesion was predilated with a retrograde balloon inserted without a guide over the retrograde wire. A 5F guide catheter was introduced next to the retrograde wire through the radial sheath (“guide parallel to wire” technique) followed by successful antegrade crossing and stenting of the mid left anterior descending artery lesion. © 2009 Wiley‐Liss, Inc.     

Review of Hardware for PTCA

There is a growing inventory of dilatation hardware at the disposal of the interventional cardiologist. The purpose of this review is to compare the distinguishing features of current and anticipated equipment which should be considered in the selection of hardware for performing coronary angioplasty (PTCA). New guiding catheters designed to improve "back-up" support for difficult anatomic variants include the hockey stick, the El Gamal, the Arani, the FR 3.5 ALT, and the AL 0.75 and ALR 1.2 Amplatz models. New "micro" dilatation catheters include the Mini-Profile and Skinny catheters, which combine independent wire movement and low profile shafts (3.5 F), and the Probe, which is currently the catheter with the lowest profile shaft (1.7 F) and balloon (0.020" for a 2.0-mm diameter balloon). The low profile of the Probe allows it to be used alongside a conventional 4.3 F dilatation catheter within the new 9 F Giant Lumen guiding catheter, which has an internal diameter of 0.088". The forthcoming "monorail" catheters will provide the operator with a low profile, "over-the-wire" system that can be exchanged for a different balloon size or a perfusion catheter without using an extension or exchange wire. Two innovations in guidewire technology are the Dilating Guide Wire (DGW) and the Buchbinder Om-niflex catheter. The DGW features a 1.5-mm diameter balloon with a deflated profile of 0.018" that can be accommodated within the Trac and Trac Plus series of dilatation catheters. The Buchbinder Omniflex catheter is designed so that the distal tip of the wire can be rotated and flexed via controls on the proximal hub of the catheter, permitting shaping of the tip without removal of the catheter. Selection of appropriate equipment from the vast array of PTCA hardware will allow the operator to minimize the cost and maximize both the safety and success of dilating a coronary stenosis. (J Interven Cardiol 1988:1:3)     

Inadvertant balloon extrusion through a side hole in a guiding catheter

A patient presented with an acute inferior myocardial infarction. Coronary angiography in the acute stage revealed total occlusion of the right coronary artery. Reperfusion was obtained after intracoronary infusion of 250,000 units of streptokinase. Angioplasty was subsequently performed because of a high grade residual stenosis. An 8-French right Judkins guiding catheter with a single side hole (USCI), a 3.0 mm balloon dilatation catheter (ACS), and a 0.018 high torque floppy guide wire (ACS) were used. After successful angioplasty angiography was repeated with the guide wire in the RCA, but the balloon was withdrawn into the guiding catheter. After injection of contrast, it was impossible to withdrawn the balloon catheter out of the guiding catheter. Fluoroscopy revealed extrusion of the balloon through the side hole in the guiding catheter.     

Angioplasty of coronary bifurcation stenoses: Immediate and long-term results of the protecting branch technique

Percutaneous transluminal angioplasty (PTCA) of coronary stenoses involving major bifurcations carries a small but significant risk of side branch occlusion which can be avoided by simultaneously using multiple dilatation systems. Among 1,275 PTCA procedures performed between 1984 and 1988 in 1,035 consecutive patients, 42 double wire procedures were applied (4%) to protect and/or dilate major coronary side branches. A total of 80 coronary stenoses were attempted of which 76 were located on a bifurcation and 4 on other segments. In the first 11 patients (group A), 2 guiding catheters were used and PTCA of each vessel was successfully performed by means of separate double lumen over-the-wire balloon catheters. In the next 31 patients (group B), 2 guidewires were advanced through a single guiding catheter and PTCA was attempted using “Monorail” balloon catheters sequentially advanced over the wires. In group B, a successful PTCA was obtained in 29 patients (93%) but twisting of the wires hampered balloon progression in 5 cases, such that dilatation could only be performed by stepping back to a single wire technique. The procedure time in group B was significantly shorter than in group A: 144 ± 30 versus 230 ± 52 minutes (p = .01). Repeat angiography was performed in 35 out of 40 patients (87%) after a mean of 180 ± 46 days following successful PTCA. Angiographic restenosis was present in 37% (24/65) of bifurcation segments which, in our experience, is not significantly different from the angiographic restenosis rate in less complex lesions (248/740; 34%; NS). It is concluded that 1) the need for using a protecting branch technique in PTCA practice is uncommon (4%); 2) among other approaches, the use of a “Monorail” system allows successful dilatation in 93% of cases with a shortened procedure time; 3) the restenosis rate at repeat angiography is similar to that of non-bifurcated lesions.     

Balloon Angioplasty of Lesions Beyond Extremely Angulated Bends

Angioplasty of stenosis beyond severely angulated bends (acute angle less than 60?) can be technically difficult. In addition to the difficulty traversing these severe bends with a guidewire, once crossed, even the lowest profile over-the-wire balloon catheter may not advance around these severe angulations. The utility of fixed-wire balloon catheters is often limited by prolapse of the distal wire tip. We describe a technique of shaping a fixed-wire balloon catheter to prevent wire prolapse while traversing severely angulated bends and its successful use in two consecutive cases where conventional methods failed.     

Fibrin Sheath Angioplasty: A Technique to Prevent Superior Vena Cava Stenosis Secondary to Dialysis Catheters

Fibrin sheaths are a heterogeneous matrix of cells and debris that form around catheters and are a known cause of central venous stenosis and catheter failure. A total of 50 cases of central venous catheter fibrin sheath angioplasty (FSA) after catheter removal or exchange are presented. A retrospective review of an outpatient office database identified 70 eligible patients over a 19-month period. After informed consent was obtained, the dialysis catheter exiting the skin was clamped, amputated, and a wire was inserted. The catheter was then removed and a 9-French sheath was inserted into the superior vena cava, a venogram was performed. If a fibrin sheath was present, angioplasty was performed using an 8 × 4 or 10 × 4 balloon along the entire length of the fibrin sheath. A completion venogram was performed to document obliteration of the sheath. During the study, 50 patients were diagnosed with a fibrin sheath, and 43 had no pre-existing central venous stenosis. After FSA, 39 of the 43 patient''s (91%) central systems remained patent without the need for subsequent interventions; 3 patients (7%) developed subclavian stenoses requiring repeat angioplasty and stenting; 1 patent (2.3%) developed an occlusion requiring a reintervention. Seven patients with prior central stenosis required multiple angioplasties; five required stenting of their central lesions. Every patient had follow-up fistulograms to document long-term patency. We propose that FSA is a prudent and safe procedure that may help reduce the risk of central venous stenosis from fibrin sheaths due to central venous catheters.     

Open-ended guidewire: new technique for balloon angioplasty of chronically occluded coronary arteries

Chronic total coronary occlusion is a growing indication to percutaneous transluminal coronary angioplasty. Since primary success of balloon angioplasty in this condition is usually limited by the difficulty of crossing the occlusion, different techniques have been described for this purpose, such as use of stiff guidewires, coronary infusion catheters, guidewires with an olive-shaped tip, or new developing methods (atherectomy, laser), in association with balloon dilatation. Here, we describe our initial experience with a thick (0.035 in) and relatively stiff open-ended guidewire, which has an inner (0.018 in diameter) lumen provided with a core wire. Several advantages are considered. The core wire yields a perfect means of steerability of the whole system, while pushability of a thicker guidewire is much greater. Moreover, the core wire can be removed, and contrast injections beyond the occlusion through the inner lumen can assure proper intraluminal location. Finally, position across the occlusion can be kept easily, since an exchange wire for conventional balloon catheters can be inserted in the inner lumen of the open-ended guidewire.     

Reopening of Chronic Coronary Artery Occlusions by Low Speed Rotational Angioplasty

Following successful application in chronic peripheral artery occlusions, rotational angioplasty was refined and miniaturized for application in patients with chronic coronary artery occlusions. The new catheter system comprises a motor-driven rotating inner steel catheter made up of several steel coils providing maximum elasticity and complete torque control with an olive-like rounded tip (1.0–1.7 mm). The catheter has a lumen for contrast injection and a shielding plastic tube. It is introduced through a conventional 8 Fr guiding catheter. The slowly rotating (200 RPM) catheter passes nontraumatically through the occlusions, thus creating a new channel with smooth contours in a "remodeling" fashion. Once the channel (diameter 1–1.5 mm) is confirmed angiographically, balloon angioplasty is performed over an exchange wire in conventional technique. The new technique was applied to patients with chronic coronary occlusions. Reopening was first attempted with conventional guidewire technique. If the occlusion could be probed with the guidewire, patients were excluded from the study. Twenty patients in whom the occlusion could not be probed with a wire were studied: 1 ACVB, 2 LAD, and 17 RCA. Average duration of occlusion was 7.4 months; it exceeded 3 months in 15/20 and 6 months in 12/20 patients. Successful reopening was achieved in 9/20 (3 from the first 10, 6 from the second 10 patients). No vessel wall perforation or any other severe complication was encountered. Residual stenosis diameter ranged from 30%–70%. Duration of occlusion was similar among patients from the successful and unsuccessful group. It is concluded that with low speed rotational angioplasty reopening of chronic coronary artery occlusions can be achieved in a considerable part of patients in whom conventional technique is unsuccessful. (J Interven Cardiol 1989:2:3)     

A complex case of angulated and bifurcated lesion facilitated by excimer laser coronary angioplasty

Angulated lesions have been shown to be associated with abrupt closure or periprocedural myocardial injury. In particular, when disease is present at the level of the angulated or bifurcated lesion, balloon dilatation may help in wire crossing but it may also cause branch occlusion. Several methods and devices have been described to manipulate coronary guidewires across angulated and bifurcated lesions. This case report describes a highly angulated coronary bifurcated lesion where, after the failure of multiple wires to cross the lesion toward the main branch, it was successfully crossed after excimer laser debulking, which facilitated the wire crossing into the main branch, without causing branch occlusion.     

冠状动脉介入术中深置指引导管技术的应用与评价

目的:分析深置指引导管技术在冠状动脉介入中的适用性和安全性。方法:在203例冠状动脉介入中采用了深置指引导管技术。涉及血管209支,包括左前降支(LAD)、左旋支(LCX)、右冠状动脉(RCA)。处理病变214处,其中C型病变占74.7%。所有病例的介入血管径路为股动脉。除4例为撤出释放了支架的球囊,余为球囊或支架难以通过病变而采用该技术。5例左主干、2例RCA开口有轻度狭窄。结果:采用深置指引导管技术进行介入的214处病变,成功处理204处,成功率95.3%。在操作成功的病例中,3例是经RCA近端已释放的支架深置指引导管,1例是经左主干支架向前降支深置指引导管,4例均成功撤出释放了支架的球囊;3例用1.5mm小球囊扩张靶病变后再深置指引导管完成后续的介入操作。1例发生左主干及LAD夹层。失败10例,其在深置指引导管下球囊或支架未能通过病变。结论:深置指引导管可有效地提高针对复杂、困难冠状动脉病变介入操作的成功率。在RCA进行该操作比较安全;但该术也可能会造成左主干及其分支内膜撕裂、夹层形成的严重并发症。     

Balloon dilatation of critical stenosis of the pulmonary valve in neonates.

Percutaneous balloon dilatation was attempted in 15 consecutive neonates (mean age 7.3 (range 1-27) days and weight 3.2 (range 2.5-4.1) kg) with critical stenosis of the pulmonary valve. Dilatation was successful in 11 (73%) patients. The mean balloon to annulus ratio was 1.1 (range 0.6-1.77). The ratio of right ventricle to femoral artery systolic pressure decreased from a mean (1 SD) of 1.4 (0.32) before to 0.8 (0.24) after dilatation and the transvalvar gradient decreased from 81 (29.7) mm Hg before to 33 (27.7) mm Hg after dilatation. All four (27%) patients in whom dilatation was unsuccessful underwent surgical valvotomy. Complications of balloon dilatation occurred in three (20%) patients; these included retroperitoneal haematoma (one) and iliofemoral venous occlusion (two). In one (7%) patient severe hypoxia and hypotension developed when the valve was crossed with a guide wire and balloon catheter. Despite successful dilatation he died 7 days after the procedure. During a mean (1 SD) follow up of 2 (1.7) years, seven (64%) of the 11 patients remained free of important restenosis. One patient required repeat dilatation three weeks after the initial procedure. In three (27%) patients restenosis developed 4-9 months after dilatation and all three had surgical valvotomy. Of the four patients initially referred for surgery three required a second operation and one required balloon dilatation. Percutaneous balloon dilatation gave effective relief of critical pulmonary stenosis in most neonates but complications and restenosis requiring surgery were common.     

Initial experience with an extendable and reusable probe balloon-on-a-wire dilatation catheter in multivessel coronary angioplasty

The “probe” balloon-on-a-wire device is an excellent balloon catheter for traversing very tight stenoses. Extending the probe by transecting its proximal inflation hub and then linking it to an extension wire has further enhanced its utility, as a wire exchange can then be performed without loosing wire access across a dilated lesion. We now report a previously undescribed technique for reconstituting and reusing an extended probe. The probe is initially transected at its proximal end. It is then extended by connecting a “Linx” wire into the open central lumen of the probe's hypotube. An over-the-wire balloon dilatation system is then substituted, via a wire exchange using a probing catheter, for final definitive dilatation. The probe is then reconstituted in the following manner. The inflation hub of the probe is recreated by modifying a standard USCI Tuohy-Borst Y adaptor and attaching this to the transected probe hypotube. It is subsequently used for dilating other stenotic arteries during multivessel angioplasty. The utility of this method was demonstrated in 5 consecutive cases. All cases underwent successful dilatations. There were no complications. This initial experience would suggest that the probe can be reused quite safely and effectively. © 1994 Wiley-Liss,Inc..     

Balloon dilatation of critical stenosis of the pulmonary valve in neonates

Percutaneous balloon dilatation was attempted in 15 consecutive neonates (mean age 7.3 (range 1-27) days and weight 3.2 (range 2.5-4.1) kg) with critical stenosis of the pulmonary valve. Dilatation was successful in 11 (73%) patients. The mean balloon to annulus ratio was 1.1 (range 0.6-1.77). The ratio of right ventricle to femoral artery systolic pressure decreased from a mean (1 SD) of 1.4 (0.32) before to 0.8 (0.24) after dilatation and the transvalvar gradient decreased from 81 (29.7) mm Hg before to 33 (27.7) mm Hg after dilatation. All four (27%) patients in whom dilatation was unsuccessful underwent surgical valvotomy. Complications of balloon dilatation occurred in three (20%) patients; these included retroperitoneal haematoma (one) and iliofemoral venous occlusion (two). In one (7%) patient severe hypoxia and hypotension developed when the valve was crossed with a guide wire and balloon catheter. Despite successful dilatation he died 7 days after the procedure. During a mean (1 SD) follow up of 2 (1.7) years, seven (64%) of the 11 patients remained free of important restenosis. One patient required repeat dilatation three weeks after the initial procedure. In three (27%) patients restenosis developed 4-9 months after dilatation and all three had surgical valvotomy. Of the four patients initially referred for surgery three required a second operation and one required balloon dilatation. Percutaneous balloon dilatation gave effective relief of critical pulmonary stenosis in most neonates but complications and restenosis requiring surgery were common.     

Guiding catheter exchange during coronary angioplasty

A new technique to exchange one angioplasty guiding catheter for another with the guide wire in place and across a coronary artery stenosis has been developed to decrease the dangers of having to recross the stenosis with a guide wire. This technique utilizes a regular extended angioplasty guide wire and enables the exchange of guiding catheters during the angioplasty procedure. In 683 consecutive angioplasty procedures by one operator, this technique has been attempted 57 times in 43 patients (6.3%) and has been successful 51 times (90%). The only failures were when the second catheter had a large or open curve (left Amplatz II, 5/22 unsuccessful or multipurpose, 1/3 unsuccessful). There have been no complications. We conclude that exchange of a guiding catheter over a guide wire by the method described is safe and helpful in cases where different guiding catheters are needed for back-up power once the lesion has been crossed with a guide wire.     

Efficacy of a new angioplasty catheter for severely narrowed coronary lesions

Conventional over the wire dilation catheters may be unsuccessful in crossing coronary lesions that are severely narrowed. Hence, a new, extremely low profile coronary angioplasty catheter specifically designed to dilate such lesions was investigated. The catheter features a 2.0, 2.5 or 3.0 mm (inflated diameter) balloon mounted on a guide wire. The deflated profile of the 2.0 mm balloon measures 0.020 +/- 0.001 in. (0.51 +/- 0.03 mm). The catheter can be used in conjunction with 7F angiographic or 8F guide catheters. The catheter was used in 61 patients, aged 43 to 86 years, with predominantly Canadian Cardiovascular Society class III-IV angina. Dilation was attempted in 77 lesions. Lesion length averaged 5.7 +/- 3.1 mm (mean +/- 1 SD), minimal diameter 0.51 +/- 0.25 mm and internal vessel diameter 2.27 +/- 0.43 mm. Sixty lesions (78%) were successfully dilated to less than 50% residual stenosis with this catheter alone; nine lesions were further dilated with a larger balloon catheter. The new catheter was unable to cross 13 lesions (17%); only 2 of these lesions were subsequently crossed with a conventional over the wire system. On the other hand, the catheter was used after failure of conventional dilating catheters in 21 lesions and was successful in 16. The new catheter was particularly valuable for distal lesions and those demonstrating 90 to 99% diameter reduction. For all lesions crossed, stenosis decreased from 76 +/- 11 to 29 +/- 12% after 2.9 +/- 2.7 inflations and peak inflation pressure of 8.0 +/- 2.9 bar. Complications were rare; coronary occlusion occurred in two lesions (3%) and dissection in three lesions (4%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Magnum Meier wires with Crag Fx wire catheter for total occlusive coronary arteries

Magnum Meier wire was used with Crag Fx wire catheter instead of Magnum balloon catheter to facilitate wire crossing through total occlusion by improving flexibility of the system without losing wire pushability. Of 372 coronary angioplasty procedures performed between January 1994 and April 1995, there were 12 subacute occlusions with an interval of 3 wk or less and 30 chronic occlusions with an interval of >3 wk. Regular over-the-wire-type balloon catheters failed to dilate four subacute occlusions and nine chronic total occlusions. Magnum Meier wire with Crag Fx wire catheter was tried for one subacute occlusion and four chronic occlusions that were undilatable with a regular balloon system and successfully dilated the subacute occlusion and three of the chronic occlusions. The lesions successfully dilated by this new approach were either long or tandem lesions in vessels that were excessively tortuous or showed an acute angle at the orifice. Thus the Magnum Meier wire with Crag Fx wire catheter can be a useful tool for dilating totally occluded lesions in tortuous coronary arteries. Cathet. Cardiovasc. Diagn. 40:198–201, 1997. © 1997 Wiley-Liss, Inc.     

Angioplasty at coronary bifurcations: single-guide, two-wire technique

A technique is described for angioplasty at coronary bifurcations. This simple approach utilizes a single guiding catheter, an exchange wire, and a conventional dilatation catheter and guidewire. With this "protective" guidewire technique, side branches at risk from occlusion during dilatation of a primary coronary segment can be protected and dilated secondarily; continual access to the threatened side branch is maintained with a "standby" exchange wire in the branch vessel.