Coronary angioplasty through a new 6 french guiding catheter

Coronary angioplasty through smaller-diameter guiding catheters using predominantly fixed-wire balloon systems has been possible, but has had some limitations. The purpose of this prospective, nonrandomized study was to investigate the results of percutaneous transluminal coronary angioplasty using a new 6F guiding catheter with over-the-wire balloon systems. Coronary angioplasty using over-the-wire balloon systems through a new 6F guiding catheter was evaluated in 79 lesions in 70 patients and then compared to randomly selected procedures using 7F guiding catheters in 70 patients performed over the same time period. Coronary angioplasty through 6F guiding catheters and over-the-wire balloons including 8 long (30-mm) and 3 perfusion balloons was successful in 94.9% of lesions and in 94% of patients. Coronary angioplasty through 7F guiding catheters was successful in 97.5% of lesions and in 97.1% of patients, respectively. Success rates between 6F and 7F guiding catheter groups were similar overall and for proximal, mid, distal, or complex (total, subtotal, or length > 10-mm) lesions. There were no failures to withdraw the deflated balloon into the 6F guiding catheter. Vessel opacification after dilatation with the guidewire across the lesion was similar between the 6F and 7F guiding catheter groups. The mean change in hematocrit for the 6F procedures (?1.4±3.7%) was significantly lower than for the 7F procedures (?3.3±3.2%, P<0.001). Coronary angioplasty using a variety of over-the-wire balloon catheters through a new 6F guiding catheter is feasible with success rates comparable to 7F guiding catheters. Angioplasty with this 6F guiding catheter reduces procedural blood loss compared to larger-lumen guiding catheters. © 1994 Wiley-Liss,Inc..     

The kissing balloon technique with two over-the-wire balloon catheters through a single 8-French guiding catheter

Some of the newer over-the-wire coronary angioplasty catheters have shaft sizes of 3.0 French (F) or less. The inner diameter of modern 8-F guiding catheters is large enough to accommodate two of such balloon catheters. We report a kissing balloon procedure with two over-the-wire catheters through a single 8-F guiding catheter.     

Left main percutaneous transluminal coronary angioplasty with the autoperfusion catheter in an animal model

Left main coronary angioplasty is associated with high risk because of interruption of blood flow to much of the left ventricle during balloon inflation. An "autoperfusion" balloon angioplasty catheter that allows blood to flow passively distal to an inflated balloon was tested in dogs and compared with inflations with standard balloon catheters. During 3 min occlusions of the left main coronary artery with the autoperfusion catheter, regional myocardial blood flow was preserved at 0.60 +/- 0.14 ml/min/g, compared with 0.07 +/- 0.03 ml/min/g during inflation with standard balloon catheters (P less than 0.01). Similarly, at the end of 3 min of inflation, left ventricular systolic pressure and dP/dt were maintained with autoperfusion catheter inflation, but they were severely depressed after standard angioplasty balloon inflation. All seven dogs survived autoperfusion balloon inflation, whereas five of seven developed sustained ventricular tachycardia and/or ventricular fibrillation during or after standard balloon inflation. Thus, distal blood flow, hemodynamics, and survival were preserved during autoperfusion balloon inflation in the left main coronary artery.     

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.     

Amelioration of ischemia during angioplasty of the left anterior descending coronary artery with an autoperfusion catheter

A new autoperfusion balloon angioplasty catheter with sideholes proximal and distal to the balloon--facilitating distal blood flow during inflation--was compared with standard angioplasty catheters in a prospective, randomized study with blinded data analysis. Hemodynamic and electrocardiographic markers of ischemia after 1 minute of standard or autoperfusion catheter inflations were compared with ischemia after control inflation with standard balloons. In the patient group randomized to standard balloon inflation only, ST-segment elevation after control inflation with a standard balloon catheter was 0.37 +/- 0.04 mV; ST-segment elevation after final balloon inflation with a standard catheter was unchanged at 0.35 +/- 0.04 mV (difference not significant). In the group randomized to the autoperfusion catheter, control inflation with a standard catheter resulted in 0.48 +/- 0.1 mV ST elevation; final inflation with the autoperfusion catheter demonstrated 0.16 +/- 0.09 mV ST elevation (p less than 0.005). Autoperfusion catheter inflation was continued for 2 minutes without change in electrocardiographic findings: ST segments remained at 0.08 +/- 0.03 mV, unchanged from 0.07 +/- 0.03 mV before angioplasty (difference not significant). Thus, while coronary angioplasty performed with standard catheters resulted in marked ST-segment elevation, in patients undergoing angioplasty with the autoperfusion catheter, ischemia was generally not seen, despite sustained balloon inflation for 2 minutes.     

A prospective randomized trial comparing the benefits and limitations of 6Fr and 8Fr guiding catheters in elective coronary angioplasty: clinical, procedural, angiographic, and economic end points

OBJECTIVES: To determine the relation between guiding catheter size, procedural and angiographic details, and cost of coronary angioplasty. BACKGROUND: Miniaturized angiographic equipment used during coronary angioplasty is proposed as a method to decrease the duration of supine bed rest, length of hospital stay, and cost of expensive inpatient hospitalization. METHODS: One hundred and sixty patients were randomized to undergo elective coronary angioplasty with a 6Fr (external diameter, 0.079-in; internal diameter 0.062-in) or 8Fr (external diameter, 0.105-in internal diameter, 0.078-0.079-in) guiding catheter. Standard balloon dilatation catheters were used. End points: 1 degree peripheral vascular complications, 2 degree technical and procedural outcomes; quantitative and qualitative quality of the coronary angiograms; and the in-hospital ("bottom up" cost accounting of equipment, supplies, support personnel, postcoronary angioplasty room), and physician cost (using Resource Based Relative Value Scale). RESULTS: There was no difference in peripheral vascular complications between the two groups (6Fr, 21%; 8Fr, 30%; P = NS). Less contrast medium was used with the 6Fr guiding catheters (6Fr, 178 +/- 102 mL; 8Fr, 257 +/- 147 mL; P = 0.0001). The qualitative quality of the angiograms was better with 8Fr than with 6Fr guiding catheters. For the entire population, the total cost of coronary angioplasty was less with 6Fr guiding catheters ($3,956 +/- $2,415) than with 8F guiding catheters ($5,073 +/- $3,985, P = 0.03). Excluding patients with either a coronary or peripheral vascular complication, there was less cost savings (6F, $3,720 +/- $1,338; 8F, $4,376 +/- 2,699, P = 0.05). Independent variables associated with increased cost included: large body mass index; hypercholesterolemia; nonionic contrast media; 8F guiding catheter; complex lesions; and duration of procedure. CONCLUSIONS: The use of smaller guiding catheters led to use of less contrast medium with a modest decrease in angiographic visualization. The cost savings seen with 6F guiding catheters is multifactorial due to smaller arteriotomy accompanying sheath insertion and reduced rate of clinically significant coronary and peripheral vascular complications.     

Monorail Piccolino catheter: a new rapid exchange/ultralow profile coronary angioplasty system

The Monorail Piccolino coronary angioplasty balloon catheter (MBC) was evaluated on 118 patients at two centers. Technical success was achieved in 110 patients (93%). Time for catheter exchange and total fluoroscopy time were significantly lower for the Monorail catheter than with standard equipment (exchange time 97 vs. 170 seconds P less than .05 and fluoroscopy time 17 vs. 88 seconds P less than .001). The advantages of rapid exchange and the ability of utilize 2 Monorail balloon catheters through one 9F guiding catheter for simultaneous inflations allowed for maximal flexibility in treating patients with bifurcation lesions. The double wire approach utilizing one Monorail balloon catheter with a 7F guiding catheter was also technically successful. The Monorail Piccolino balloon catheter has unique features that allow for greater ease of operator use, rapid catheter exchange, and optimal angiographic visualization. It is felt that this catheter design provides distinct advantages over standard angioplasty equipment.     

Monorail™ Piccolino catheter: A new rapid exchagne/ultralow profile coronary angioplasty system

The Monorail^TM Piccolino coronary angioplasty balloon catheter (MBC) was evaluated on 118 patients at two centers. Technical success was achieved in 110 patients (93%). Time for catheter exchange and total fluoroscopy time were significantly lower for the Monorail catheter than with standard equipment (exchange time 97 vs. 170 seconds P <.05 and fluoroscopy time 17 vs. 88 seconds P < 0.001). The advantages of rapid exchange and the ability of utilize 2 Monorail balloon catheters through one 9F guiding catheter for simultaneous inflations allowed for maximal flexibility in treating patients with bifurcation lesions. The double wire approach utilizing one Monorail balloon catheter with a 7F guiding catheter was also technically successful. The Monorail^TM Piccolino balloon catheter has unique features that allow for greater ease of operator use, rapid catheter exchange, and optimal angiographic visualization. It is felt that this catheter design provides distinct advantages over standard angioplasty equipment.     

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.     

Coronary stenting using a 6 F. diagnostic catheter: a report of two cases

Standard guiding catheters for coronary interventions may not selectively engage the coronary ostium despite a successful cannulation with a diagnostic catheter of the same curve. This discrepancy is explained by a slight difference in shape between the two catheters (shorter tip of the guiding, absence of tip tapering, etc.). The authors report on the use of 6 F. coronary diagnostic catheters as guiding catheters for coronary angioplasty and stent implantation in two patients with critical stenoses: in the right coronary artery distal to a right internal mammary artery anastomosis in one and in the ostial right coronary artery in the other. In both cases, the use of diagnostic catheters was the key to success despite the vessel orifice being unfavourable for the use of different types of guiding catheters. (Int J Cardiovasc Intervent 2000; 3:41–45)     

Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls.

Prolonged angioplasty balloon inflation with an autoperfusion balloon for failed conventional coronary angioplasty, was compared with emergency surgery for this condition. Restenosis was assessed 6 weeks after successful intervention with the autoperfusion balloon. Forty consecutive patients with persistent acute occlusion and/or severe intimal dissection during conventional angioplasty, were treated with the autoperfusion balloon. They were candidates for emergency surgery if it failed. Total inflation time was significantly longer (p < 0.001) with the autoperfusion balloon (27.5; 10-180 min) than with the standard balloon (10; 1-20 min) (median; range). The number of inflations was significantly lower (p < 0.001) with the autoperfusion balloon (2; 1-5 times) than with the standard balloon (5; 2-14 times) (median; range). Two patients died, one before surgery could be performed. The autoperfusion balloon was successful in 26 patients (65%). After 6 weeks, 16 (62%) were asymptomatic without anti-anginal medication, 24 underwent repeat angiography, 10 (42%) had restenosis, 7 (27%) underwent elective bypass surgery. Emergency surgery remained necessary in 13 patients (33%), 9 received arterial grafts. In 31 retrospective controls, who had undergone immediate surgery for the same indication, only venous grafts could be used. Thus, prolonged autoperfusion balloon inflation was successful in 65% of the cases of failed, conventional angioplasty. The angiographic restenosis rate after 6 weeks was 42%. If emergency surgery remained necessary, the autoperfusion balloon facilitated the use of arterial bypass grafts.     

Role of Autoperfusion Balloon in Endovascular Interventions

The development of the autoperfusion balloon catheter provided the ability to perform prolonged balloon inflations during angioplasty procedures. For a number of years the autoperfusion balloon catheter was successfully used to treat acute complications of percutaneous coronary interventions. However, with the advent of stent implantation procedures and the use of platelet glycoprotein IIb/IIIa receptor inhibitors, the role of autoperfusion balloon angioplasty has decreased. However, the perfusion balloon may have an important role in angioplasty and/or stenting of coronary lesions with unfavorable coronary anatomy and also in carotid angioplasty. The perfusion balloon also may be helpful for the treatment of in-stent restenosis. In the future the autoperfusion balloon or its principle may hold promise in emerging interventions, such as gene therapy and vascular brachytherapy where prolonged interrupted of coronary circulation is required.     

Randomized evaluation of six French Voda-type guiding catheters for left coronary artery balloon angioplasty

In order to evaluate 6 French (6F) Voda-type guiding catheters for left coronary artery balloon angioplasty, we randomized the choice of the guiding catheter in 100 consecutive patients between a Voda (group 1, n = 50) and a Judkins or Amplatz curve (group 2) guiding catheter. Angioplasty success rate (98% for both), need for guiding catheter crossover exchange (2 in group 1 vs. 1 in group 2), fluoroscopy time, and volume of injected contrast were similar in both groups, but the operator's appreciation of good back-up support was better with the Voda-type guiding catheter (90% vs. 74%, P < 0.05). No complications attributed to the guiding catheter were noted in either group. Efficiency of the Voda-type guiding catheter appeared similar for both left anterior descending (n = 35, success rate 100%) and circumflex (n = 18, success rate 94%) coronary artery angioplasty. Voda-type guiding catheters are an efficient and safe approach to routine left coronary angioplasty. They appear to be as effective as a choice bewtween a Judkins or an Amplatz configuration and could be of particular use when a double angioplasty of the left anterior descending and circumflex arteries is attempted during the same procedure. © 1995 Wiley-Liss, Inc.     

Preservation of distal coronary perfusion during prolonged balloon inflation with an autoperfusion angioplasty catheter

A newly designed balloon coronary angioplasty catheter that allows passive antegrade blood flow during balloon inflation (autoperfusion catheter) was compared with a standard balloon coronary angioplasty catheter. In a randomized sequence, inflations were performed for 3 min in the left circumflex coronary artery of 12 dogs with the standard catheter followed by the autoperfusion catheter or vice versa. During inflation with the standard catheter, the ST segment of standard limb lead II increased from -0.02 +/- 0.03 mV to 0.39 +/- 0.08 mV (p less than .001), whereas during inflation with the autoperfusion catheter the ST segment did not change (-0.03 +/- 0.03 vs -0.01 +/- 0.04 mV; p = NS). Regional myocardial blood flow measured by the radioactive microsphere technique in the posterior subepicardium and subendocardium was 0.12 +/- 0.03 and 0.08 +/- 0.03 ml/min/g, respectively, with the standard catheter as compared with 0.57 +/- 0.08 and 0.61 +/- 0.14 ml/min/g with the autoperfusion catheter (both p less than .01 compared with the standard catheter). Thus, unlike the standard catheter, the autoperfusion catheter allows for inflations up to 3 min in duration without producing deleterious changes in the ST segment or severe reductions in regional myocardial blood flow.     

The autoperfusion balloon angioplasty catheter limits myocardial ischemia and necrosis during prolonged balloon inflation

A new balloon angioplasty catheter with multiple proximal and distal side holes has previously been shown to allow significant protection from ischemia during a 3 min balloon inflation in a coronary artery. Because of the potential benefits of very long periods of inflation, 21 anesthetized thoracotomized dogs were randomized to left circumflex coronary artery occlusion with either a standard or an autoperfusion balloon catheter for 90 min. Nine dogs sustained ventricular fibrillation before completing the study, eight after standard balloon inflation and one after autoperfusion balloon inflation (p = 0.04). ST segment elevation was 0.45 +/- 0.13 mV after 15 min of standard balloon inflation versus -0.03 +/- 0.03 mV after autoperfusion balloon inflation (p less than 0.001). Regional myocardial blood flow was 0.02 +/- 0.01 ml/min per g after 30 min of standard balloon inflation compared with 0.78 +/- 0.23 ml/min per g in the group subjected to autoperfusion balloon inflation (p = 0.01). The area of necrosis/area at risk in the standard catheter group was 40.4 +/- 19.3% versus 1.2 +/- 1.2% for the autoperfusion catheter group (p = 0.01). Thus, the autoperfusion catheter preserves blood flow and limits myocardial ischemia and necrosis despite 90 min of balloon inflation.     

Coronary balloon angioplasty through diagnostic 6 French catheters

We investigated the use of ultralow profile balloon catheters (Scimed ACE, USCI Probe, Cordis, Orion) for coronary angioplasty through 6 French diagnostic catheters (Schneider, Cordis). Contrast injection was assisted with a Hercules pump (Cordis) in all cases. During 21 procedures, angioplasty of 27 lesions in 20 selected patients was attempted (1.3 lesion/procedure). Twelve lesions were in the right, 10 in the left anterior descending, and 5 in the left circumflex coronary artery. Balloon size varied between 2.5 and 3.5 mm. Twenty lesions could be successfully dilated (74%) through the 6 French catheter and 7 lesions required an exchange to a 7 French angioplasty guiding catheter. For 5 cases, another balloon was also necessary to complete the procedure. The final overall success rate was 100% per patient and per lesion and there were no major complications. Despite the small internal catheter lumen (1.22 mm) coronary visualization was adequate, and mechanical support was good. Failures of 6 French catheters were attributed to insufficient torque control and excessive friction when the balloon crossed the tapered end of the diagnostic catheter. Coronary angioplasty through a diagnostic 6 French catheter is feasible and may represent a reasonable alternative for simple cases that are done during the same session as the diagnostic angiography. Once available, 6 French high flow angioplasty guiding catheters without a tapered tip should improve success while retaining the advantage of a small femoral puncture site.     

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.     

A technique for changing a ptca balloon catheter over a regular-length guidewire

In 100 patients who underwent coronary angioplasty with more than one balloon catheter for a lesion, these over-the-wire balloon catheters were changed by using a regular-length guidewire. In order to change to another balloon, the inflation device was connected to the central guide wire lumen of the catheter after pulling back the catheter until the proximal end of the regular length guide wire disappeared. By pulling back the balloon catheter from the guiding catheter by applying a pressure with the inflation device, the balloon was taken out of the guiding catheter leaving the wire in the coronary artery. One hundred forty-nine of 163 attempted procedures were completed successfully. Our technique helped in performing a fast, safe, and reliable changing procedure compared to the procedure with an extended guidewire. © 1994 Wiley-Liss,Inc..     

Percutaneous transluminal angioplasty of stenotic saphenous vein right coronary bypass grafts utilizing a peripheral balloon dilatation catheter without a guiding catheter

Effective angioplasty of stenosed saphenous vein coronary bypass grafts may be impossible with the standard-size coronary dilatation catheters because the large diameter of these grafts results in unacceptable balloon-to-vessel ratios. We avoided this problem by using a peripheral arterial dilatation catheter with an inflation diameter of 6 mm and obtained a satisfactory short- and long-term result in two patients in whom previous attempts with the largest coronary dilatation catheter (4 mm) had failed. This technique, which precludes the use of a guiding catheter, is suitable only for right bypass grafts.     

Experience with the use of coronary autoperfusion catheter during complicated angioplasty

Between February and July of 1989, 22 patients underwent the use of the Stack autoperfusion catheter following acute occlusion or obstructive dissection during coronary angioplasty; in 20 cases conventional balloon was used in an attempt to correct the angiographic appearance followed by the use of Stack catheter when results were sub-optimal. Only 1 patient (4.5%) required surgical revascularization. Although our study is not prospective or randomized, our observations suggest a significant impact in decreasing the need for emergency surgical revascularization after complicated coronary angioplasty with the use of this approach.