Angioplasty of unusually large coronary arteries using the hugging balloon technique via a single guiding catheter

Unusually large native coronary arteries, in particular those supplying expansive regions of myocardium, may not be adequately dilated using currently available coronary angioplasty catheters. The "hugging balloon" technique, in which two dilatation catheter balloons are simultaneously inflated side-by-side, has been previously described for lesions in large saphenous vein grafts using the double guiding catheter (and dual entry site) technique. With the development of large lumen guiding catheters and lower profile dilatation catheters, we report the initial use of the hugging balloon technique via a single guiding catheter in oversized native coronary arteries.     

Angioplasty techniques for stenoses involving coronary artery bifurcations

Branch occlusion during coronary angioplasty is an infrequent but potentially serious complication. The overall incidence of branch occlusion during dilatation of a primary vessel is 5%. Branch vessels most jeopardized by dilatation generally have a complex plaque that not only involves the target vessel but also extends into the origin of the branch vessel. Branches free of pathology at their origin generally have an exceedingly low incidence of occlusion during adjacent balloon dilatation. Side branches at risk for occlusion should be "protected" if the branch vessel is of an important size that could be dilated with a conventional dilatation catheter. The advent of lower profile dilatation catheters and guidewires has provided an opportunity to introduce several pieces of dilatation hardware into the coronary system through a single guiding catheter. Several techniques are described for both "protecting" and dilating side branches, either simultaneously or secondarily, after balloon dilatation of a primary vessel.     

Evaluation of catheters and metallic catheter markers as calibration standard for measurement of coronary dimension

Measurement of coronary dimension requires an accurate and reproducible dimensional reference. Angiographic catheters are frequently used for this purpose. We measured the angiographic diameters of a broad range of diagnostic and angioplasty guiding catheters by using two commonly used edge-detection algorithms. Angiographic diameters are significantly less than true catheter outer diameter. Therefore the use of contrast-filled catheters as a dimensional reference may lead to considerable error in vessel measurement with overestimation of absolute dimension. Tables of reference values for multiple catheter as calibration standard, tested under a variety of angiographic conditions. The metallic-tipped marker was found to have a better degree of reproducibility than catheters. These findings have implications for studies employing serial measurements of coronary artery dimension and for the clinical practice of estimating vessel diameter for choice of balloon size during angioplasty.     

Coronary angioplasty using an autoperfusion balloon catheter through a 6 french guiding catheter

Use of 6 French guiding catheters for elective percutaneous transluminal coronary angioplasty has been limited by lack of a compatible autoperfusion balloon catheter for management of complications such as acute vessel closure and large subintimall dissections. We describe the successful use of a lower profile autoperfusion balloon catheter through large internal lumen 6F guiding catheters for elective coronary angioplasty. These cases demonstrate the feasibility of the use of autoperfusion balloon catheters with 6F guiding catheters in elective, and presumably also in emergent, settings. © 1993 Wiley-Liss, Inc.     

Balloon crush: treatment of bifurcation lesions using the crush stenting technique as adapted for transradial approach of percutaneous coronary intervention.

The recent advent of drug-eluting stents has allowed the crush stenting technique to be adopted, thus simplifying the treatment of bifurcation coronary artery lesions. However, this can only be achieved in 7 Fr or greater guiding catheters, hence precluding most transradial percutaneous coronary interventions that are usually undertaken using 6 Fr or less guiding catheters. We assessed the feasibility of balloon stent crush as a stepwise procedure in achieving bifurcation crush stenting in 6 Fr transradial percutaneous coronary interventions. Since it is not possible to place two stents through a 6 Fr guiding catheter, we have adapted the crush stenting technique by initially placing a stent in the side branch and a balloon in the main vessel. The side branch stent is then deployed against the main vessel balloon that is later inflated, crushing the side branch stent within the main vessel. The main vessel is then stented and the side branch recrossed for kissing inflations. Seven patients (five males; age range, 47-78 years) with bifurcation lesions were treated using the above-described technique without major complications. Balloon crush of the side branch stent were successfully achieved in all cases without balloon trapping. In six cases where side branch recrossing was attempted, all were successful and kissing balloon inflations were undertaken in five cases. We have demonstrated that the modified crush stenting technique is feasible and can be safely adapted for use in a 6 Fr transradial percutaneous coronary intervention approach.     

Percutaneous coronary angioplasty of large venous graft using peripheral dilatation catheter

The maximum inflated diameters of standard percutaneous transluminal coronary angioplasty (PTCA) balloon catheters can be insufficient if stenoses in oversized venous grafts are to be dilated. As an alternative to the recently described "hugging balloon" technique, it seems feasible to use a standard peripheral angioplasty (PTA) catheter with a balloon diameter that is matching to the vessel. Such a procedure calls for a free long-wire exchange and may be hampered by the stiffness of a PTA catheter. We report a case where this technique, used in an emergency procedure, resulted in a satisfactory angiographic result without causing complications.     

Percutaneous transluminal coronary angioplasty using a combined "balloon-on-a-wire" system and exchange guidewire technique

New balloon-on-a-wire dilation systems allow crossing of severely stenosed coronary arteries owing to their ultra-low profile. However, these systems do not allow for over-the-wire exchange to a larger balloon catheter or insertion of perfusion catheters, should the vessel close abruptly during dilation. Therefore, if the need for such catheters arises, the vessel must be left unprotected during attempts to recross the lesion. We describe a new technique using a combined balloon-on-a-wire system and an exchangeable guidewire, which permits the crossing and dilation of severely stenosed coronary arteries, while at the same time offering vessel protection and balloon catheter exchange.     

Percutaneous transluminal coronary angioplasty using a combined “balloon-on-a-wire” system and exchange guidewire technique

New balloon-on-a-wire dilation systems allow crossing of severely stenosed coronary arteries owing to their ultra-low profile. However, these systems do not allow for over-the-wire exchange to a larger balloon catheter or insertion of perfusion catheters, should the vessel close abruptly during dilation. Therefore, if the need for such catheters arises, the vessel must be left unprotected during attempts to recross the lesion. We describe a new technique using a combined balloon-on-a-wire system and an exchangeable guidewire, which permits the crossing and dilation of severely stenosed coronary arteries, while at the same time offering vessel protection and balloon catheter exchange.     

New technic for guidable balloon dilatation of coronary vessel stenoses

A new technique for steerable balloon dilatation is described. In contrast to the usual procedure the stenosis is first crossed by a long wire only. To minimize injuries to the vessel wall the wire is equipped with a thickened ball-shaped tip. After the stenosis has been crossed and the wire tip sufficiently advanced the balloon catheter is inserted over the long wire. If necessary the balloon catheter can be removed and another inserted without repeat crossing. If an occlusion is caused by the process of dilatation a perfusion catheter can be advanced distal to the occlusion. Perfusion can be performed with the aid of a simple syringe-tap system because the cross sectional area of this catheter is much larger than a single lumen of the double-lumen balloon catheter. This procedure even allows the dilatation of branching stenoses through the same guiding catheter whereas for the usually performed "kissing balloon" technique two guiding catheters are required. Preliminary experience with 80 patients has shown that crossing of stenoses is facilitated by the new technique because steering of the guide wire and display by contrast medium injections are unhindered. If required the balloon catheter can be changed for another one without difficulty. In the case of an occlusion the lesion can be crossed again without any risk and repeat dilatation or coronary perfusion can be performed.     

New techniques for guiding catheter management during directional coronary atherectomy

Directional coronary atherectomy (DCA) is an important advance in the mechanical revascularization of stenotic coronary arteries. The bulky nature of the DCA device has necessitated the use of guiding catheter designs that are more cumbersome to use than balloon angioplasty guiding catheters. Because engagement of coronary artery ostia with the currently available DCA guiding catheters is often difficult and because DCA guiding catheters significantly “relax” and reshape during the atherectomy procedure, angiography using these guiding catheters before and after atherectomy can be suboptimal. A new technique for angiography during atherectomy using long Judkin's diagnostic catheters inserted through the existing DCA guiding catheters is described. This technique can be used for optimal visualization of the coronary arteries with minimal use of contrast before and after sessions of atherectomy and also can be used to help engage the DCA guiding catheters. Some improvements in the design of guiding catheters for DCA are suggested. © 1993 Wiley-Liss, Inc.     

Histopathologic examination of material from angioplasty balloon catheters used in vivo in human coronary arteries

Reports on vascular pathology post-PTCA in both human and animal coronary vessels have revealed medial and intimal cracks and tears, thrombus formation, platelet accumulation, and loss of endothelial cells. The extent and type of damage can currently be assessed in vivo at the macro level by means of coronary artery angiography. However, this technique cannot define vessel wall characteristics at the cellular level. Our hypothesis is that vessel wall material may adhere to the balloon and thus provide a source for coronary artery cytological investigation in vivo. Ten balloon catheters were evaluated to discern any material which was dislodged from the coronary artery and which remained attached to the balloon catheter or guide wire. Our results indicate that angioplasty catheter balloons frequently have adherent collagen, endothelial cells, organized thrombus, and plaque with obvious cholesterol clefts, that can be retrieved and examined histologically. We conclude that material is often dislodged from the plaque during PTCA. In addition, plaque material removed by the balloon catheter offers an unusual opportunity to analyze the morphologic characteristics of cells from the human coronary artery in vivo.     

Successful transluminal coronary angioplasty facilitated only by guidewire support

We describe a case where extreme tortuosity in the patient's iliac arterial system precluded the manipulation and therefore engagement of 8 Fr guiding catheters with our target vessel. After diagnostic coronary angiography was performed with 6 Fr catheters, successful balloon angioplasty was negotiated over a stiff guidewire without guiding catheter support. Balloon dilatation of the ostial stenosis enabled subsequent engagement with 8 Fr guiding catheter and successful stent delivery. Cathet. Cardiovasc. Intervent. 46:467–469, 1999. © 1999 Wiley-Liss, Inc.     

Slender distal radial five French coronary shockwave lithotripsy

Despite technological evolution, percutaneous coronary interventions targeting coronary calcifications remain challenging and associated with high rates of complications and adverse outcomes. Over the years, rotational atherectomy has emerged as the reference treatment of calcified coronary artery lesions despite some inherent limitations. Also, rotational atherectomy typically requires relatively large guiding catheters which may unfavorably impact on the decision for transradial access, especially when radial artery is small, and consequently offset the relevant clinical benefits associated to transradial access. Recently, a new technology has been introduced in interventional practice to implement coronary lithotripsy. The device implements multiple small emitters enclosed in a coronary balloon creating sonic pressure waves to selectively fracture calcium within the plaque and favorably modify vessel compliance. Owing to its specific design, coronary shockwave lithotripsy could be used with small bore guiding catheters which may allow for straightforward transradial percutaneous treatment of calcified coronary lesions even in patients with a small radial artery. To illustrate this concept, we report the first experience of slender transradial coronary shockwave lithotripsy with a five French sheathless guiding catheter.     

Successful stent delivery through 5 French guiding catheter

BACKGROUND AND OBJECTIVE: In vessels with moderate-severe tortuosity, rigidity or calcium, 6 French guiding catheters may be of help in stent delivering, allowing a deep coronary intubation and, hence, an easier coronary stent advancement. In this study, we describe our experience in coronary stenting using 5 French guiding catheters. METHODS AND RESULTS: The study population is constituted by 46 patients in whom coronary stenting was attempted through a 5 French guiding catheter. Sixty-six stents were delivered in 56 vessels; the 5 French Zuma guiding catheter (MedtronicAVE, Minneapolis, Minnesota) was used. In 74% of cases, a moderate-severe tortuosity was present, and calcium was visible by fluoroscopy in 27%. The stented lesions were de novo in 95%, and 42% of stents were placed in the right coronary artery. The stent was successfully delivered and implanted in all but one case (98.5%). In one patient with severe vessel tortuosity, a successful balloon dilation was performed, but the stent could not be successfully advanced through the coronary artery to the left anterior descending, and could be retrieved without any complication. Changing to a larger size guiding catheter was not required in any patient. Balloon predilation was performed before coronary placement in 41 of the 66 stents (62.1%), whereas stents were directly implanted without balloon predilation in the remaining 25 cases (37.9%). CONCLUSION: Coronary stenting through 5 French guiding catheters is feasible. This strategy may be especially indicated in patients with moderate-severe vessel tortuosity.     

应用5F引导导管经桡动脉行冠状动脉介入治疗

目的 评价应用5F引导导管经桡动脉行冠状动脉(冠脉)介入治疗(PCI)的可行性、安全性及优越性，探讨其应用策略。方法 应用5F引导导管经桡动脉对120例患者的166处病变进行PCI，桡动脉穿刺成功后动脉鞘内注入维拉帕米5mg，根据造影显示冠脉起始段和病变近端的情况选择合适引导导管，按常规进行PCI操作；术后立刻拔出鞘管，加压包扎穿刺处，4h后解除加压包扎；术后仅限制患者穿刺侧上肢活动。结果 右冠脉(RC)病变43例中有67．4％应用Judkins RC导管(JR)，32．6％应用Amplatz导管。92例患者的121处左冠脉(LC)病变，66．3％应用Judkins LC导管，18．5％应用EBU导管，15．2％应用Amplatz LC导管。2例静脉旁路病变均应用JR。PCI成功率97％；5处(3％)仅行经皮冠脉成形术未成功；并发症仅有1例(0．8％)桡动脉闭塞，但不影响手部供血。结论 应用5F引导导管经桡动脉行PCI具有可行性，由于导管细软，大大降低冠脉和穿刺部位的并发症，具有很高的安全性和优越性；但操作难度较大，需掌握导管的选用策略，以增加导管的支持力和同轴性，提高成功率。     

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)     

Hugging balloon angioplasty of right coronary artery

We report a case of “hugging balloon” dilatation of a giant right coronary artery using two dilatation catheters, a balloon “on a wire” and a balloon “rapid exchange” systems via a single guiding catheter. The necessity of larger PTCA balloon catheter (>4.0 mm) was stressed.     

Relief of pressure damping during coronary angioplasty: a device for creating side holes in PTCA guiding catheters

Percutaneous coronary angioplasty guiding catheters occasionally wedge in the coronary orifice and obstruct blood flow, making completion of the balloon dilatation difficult. Side holes may be made in the catheter, but when created free-hand may not be ideal. This report describes a device for creating side holes of small size, with uniform shape, and without rough edges. The disadvantages of dye extravasation and loss of strength in the catheter are minimized.     

Percutaneous transluminal angioplasty involving internal mammary artery bypass grafts: a femoral approach

Percutaneous transluminal coronary angioplasty is an effective technique for the treatment of selected patients with ischemic heart disease due to coronary artery stenosis. Successful angioplasty in saphenous vein bypass grafts has been documented, but little experience has been reported using angioplasty in internal mammary artery to coronary artery bypass grafts. Nine of ten patients with stenosis in the internal mammary artery to coronary artery anastomosis or in the coronary vessel distal to the anastomosis site were successfully treated with angioplasty. One patient developed restenosis 1 month after the procedure, and a repeat angioplasty was successful. In one patient, the balloon catheter could not be advanced through the left internal mammary artery to the stenosis site. Technical features of internal mammary artery angioplasty are discussed, including the use of specially designed guiding wires, guiding catheters, and balloon catheters that facilitate angioplasty involving internal mammary arteries from the femoral approach.     

Double-wire angioplasty of the right coronary artery bifurcational stenosis

Two cases of distal right coronary artery (RCA) bifurcational stenoses involving ostia of the posterolateral (PLA) and the posterior descending (PDA) branches in patients who underwent successful coronary angioplasty using a double-wire technique are reported. A single guiding catheter and sequential balloon inflations were utilized in one, and two guiding catheters and simultaneous balloon inflations in the other. The indications, techniques, and outcomes are described.