Intracoronary separation of a nosecone: an unusual complication of directional atherectomy.

A rare case of coronary separation of nosecone fixed to a 6 Fr GTO cutter catheter after failed directional coronary atherectomy (DCA) is reported. Revascularization was successful using a stent via the subintimal neolumen beside the nosecone. Heavily calcified lesions are relative contraindications to DCA.     

Catheter separation during cardiac catheterization and coronary angiography. A report of four incidents and review of the literature

Four incidents of catheter separation in three patients during left heart catheterization and coronary angiography are presented. In two cases the catheters had been used before. After the second incident, we decided to use angiography catheters once only. All catheter fragments were removed under local anesthesia, and no further complications arose. In all incidents the point of catheter fracture was near the bond between the body of the catheter and its tip. We believe that catheter separation is related to polymer aging. The catheters in the third and fourth incidents were unused, but there was no expiration date on their packages. We recommend that expiration dates be clearly stated on every catheter package, catheter manufactures issue warnings not to use catheters after expiration date, and unused angiography catheters with no expiration date not be used. We also suggest that consideration be given to using catheters once only.     

Complete fracture of an Ikari guiding catheter in the axillary artery during transradial coronary intervention

Complete fracture of a guiding catheter during percutaneous coronary intervention is an exceedingly rare but potentially serious complication. The present case report describes the complete fracture of an Ikari guiding catheter and the various manoeuvres used to retrieve the broken catheter fragment. The anatomy and limited space in the radial and axillary arteries made it possible for the catheter to twist on itself during a difficult cannulation, resulting in its complete fracture and separation. The present case highlights the need for caution in the manipulation of an Ikari guiding catheter by the transradial approach.     

Improved stability and visualization during coronary artery angioplasty using a double catheter technique

Guiding catheters used in coronary angioplasty can make coronary angioplasty potentially hazardous when they become positionally unstable, induce myocardial ischemia, or impair angiographic visualization. In order to avoid this problem, a double catheter technique was employed in seven patients involving nine procedures consisting of a standard 8 or 9 French angioplasty guiding catheter and a standard 7 French angiographic catheter to prevent coronary flow reduction and to permit improved coronary artery visualization. In two of the procedures, the second diagnostic catheter also permitted the prevention of potential plaque disruption by the guide catheter in the proximal right coronary artery. The predilatation stenosis was 88 +/- 12%; the postdilatation stenosis was 28 +/- 9%. The use of the diagnostic catheter as a second catheter prevented damping and permitted the stable disengagement of the guiding catheter from the coronary artery. This technique is most useful in patients who have proximal right coronary artery stenoses because it provides optimal visualization of the segment undergoing dilatation, avoids the potential for ischemia in more distal stenoses, and thereby allows the procedure to be performed in a controlled, unhurried manner.     

Subselective measurement of coronary blood flow velocity using a steerable Doppler catheter

The accuracy of coronary arteriography to predict obstruction to coronary blood flow has recently been questioned. Assessment of coronary hemodynamic variables and vasodilator reserve may provide more reliable information regarding the significance of coronary stenosis. To provide a clinically safe and reliable method of measuring coronary blood flow velocity and coronary flow reserve, a 3F steerable Doppler catheter capable of subselective placement in the coronary circulation was developed and validated in an animal model. Coronary blood flow velocity measured with the catheter correlated with simultaneous measurements by a previously validated external cuff type Doppler probe (r = 0.97), coronary sinus flow collections (r = 0.78) and femoral artery flow collections (r = 0.96). The extravascular Doppler cuff measurements of rest flow velocity and vasodilator reserve were not significantly different with or without the catheter in the artery, indicating that the Doppler catheter caused no obstruction to blood flow. The Doppler catheter has recorded stable and reproducible signals without complications in 28 patients, including 62 separate arterial cannulations. Thus: 1) the 3F Doppler coronary catheter is nonobstructing, steerable and safe; 2) there is an excellent correlation of blood flow velocity with volume collections; and 3) the catheter provides a reliable method of determining coronary blood flow velocity and coronary vasodilator reserve.     

Clinical experience of percutaneous coronary angioscopy in cases with coronary artery disease

Direct visualization of the coronary arteries was performed by using a new ultrathin angioscopic catheter system in experimental animals and 4 patients with coronary artery disease during percutaneous transluminal coronary angioplasty (PTCA). In this catheter system, inspection of the coronary arteries was achieved during washout of blood by bolus infusion of 8-10 ml of saline into the coronary artery through the guide catheter. In the preliminary experience with this coronary angioscopic system, there were some limitations. In 2 patients, removal of coronary blood by manual injection of saline was not adequate, and diagnostic TV images could not be obtained. In 2 patients with tortuous coronary arteries, the catheter could not pass to the atheromatous plaques owing to lack of flexibility of the fiberoptic catheter. Furthermore, angina pectoris occurred in 2 patients during angioscopy, owing probably to interference with coronary blood flow by the guide catheter and/or fiberoptic catheter itself. For future clinical application of coronary angioscopy, further improvements in the instrument are necessary.     

Transluminal intracoronary reperfusion catheter: a device to maintain coronary perfusion between failed coronary angioplasty and emergency coronary bypass surgery

The reperfusion catheter is a 4.3F catheter with 30 holes over its distal 10 cm. It is used to maintain coronary blood flow in patients awaiting emergency coronary bypass surgery after failed coronary angioplasty. The insertion of the reperfusion catheter was attempted in 20 patients (14 with total occlusion and 6 with severe residual stenosis judged to be in jeopardy of reclosure before operation). The reperfusion catheter was successfully placed across the obstruction in 18 patients (90%). After successful insertion of the reperfusion catheter, 16 patients had good anterograde flow (Thrombolysis in Myocardial Infaction [TIMI] trial grade II or III); angiographic improvement was associated with significant lessening of ST segment elevation as well as a decrease in chest pain in most patients. Two patients had poor or absent anterograde flow (TIMI grade O or I) because of extensive preexisting intracoronary thrombosis; one died from refractory ventricular fibrillation. In each of the remaining patients emergency coronary bypass surgery was performed with no deaths or significant cardiac complications. The reperfusion catheter is a safe and effective method to reestablish and maintain coronary blood flow before coronary bypass surgery after failed coronary angioplasty. Because there is the potential risk of serious complications, particularly thrombus formation within this catheter, the reperfusion catheter should be used cautiously and the patient should undergo immediate bypass surgery.     

Modified heparin-bonded catheter for cannulation of the coronary sinus from the femoral vein

Serial sampling from the coronary sinus is an attractive technique for drawing blood samples to be used in the characterization of procoagulant activity during coronary interventions. We have developed a modified Simmons catheter for rapid cannulation of the coronary sinus from the femoral approach. The catheter design incorporates heparin bonding and distal side-holes to minimize blood sampling artifacts. Coronary sinus cannulation was performed via the femoral approach in 186 patients by use of a multipurpose catheter (n = 8), an unmodified Simmons I or II catheter (n = 64), or the modified Simmons catheter (n = 114). The coronary sinus was cannulated successfully with the modified Simmons catheter in 97% of patients; the success rate with the unmodified Simmons II catheter was 87% (P = 0.02). The modified Simmons catheter represents an improved technique for cannulation of the coronary sinus from the femoral vein. © Wiley-Liss, Inc.     

Coronary Thromboembolism with Fatal Outcome Following Coronary Angiography

ABSTRACT A case of fatal thromboembolic occlusion of the left coronary artery at selective coronary arteriography is described. The course of events and the findings at autopsy suggest that thrombotic material was deposited on one intravascular catheter and transferred to a second catheter inserted over the same guide wire. Contrast injection through the second catheter into the left coronary ostium resulted in immediate and fatal occlusion of the two major branches of the left coronary artery.     

Long-tip guiding catheter: successful and safe for left coronary artery angioplasty.

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150-180 degrees) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, approximately 20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

New catheter design for cannulation of the anomalous right coronary artery arising from the left sinus of valsalva.

Cannulation of an anomalous right coronary artery during coronary angiography and percutaneous intervention poses significant technical difficulties using currently available catheter shapes. We describe a new catheter design and the cannulation technique for application of this catheter. The initial experience with this catheter in cases is reported.     

Coronary artery pseudo-occlusion associated with the use of an active hemoperfusion system during PTCA

We describe the phenomenon of coronary artery "pseudo-occlusion," which may occur when active hemoperfusion devices are utilized during percutaneous transluminal coronary angioplasty (PTCA). In such cases, contrast injected via the guiding catheter fails to opacify the coronary artery distal to the tip of the dilating catheter, thereby giving the angiographic appearance of coronary occlusion. When active hemoperfusion is terminated, contrast opacifies the vessel in a normal fashion. The cause of this observation is likely multifactorial and includes obstruction to flow by the dilating catheter, high distal pressure delivered by the dilating catheter during hemoperfusion competing with the flow of contrast injected via the guiding catheter, and wash-out of contrast at the tip of the dilating catheter by non-contrast containing blood being pumped through the system. This phenomenon must be recognized if potentially deleterious repeat dilatations are to be avoided.     

Successful Percutaneous Coronary Intervention of an Anomalous Right Coronary Artery With High Anterior Takeoff Using a DIO Thrombus Aspiration Catheter

Selecting an appropriate guiding catheter is the most important determinant of procedural percutaneous coronary intervention success, especially with an anomalous right coronary artery with high anterior takeoff, which is rather complicated. We present a case of successful stent implantation in an anomalous right coronary artery with high anterior takeoff using DIO thrombus aspiration catheter. This method is useful when selection of the guiding catheter is rather complicated such as in the case of congenital coronary anomalies.     

三维右冠状动脉造影导管在右冠状动脉造影中的应用

目的比较三维右冠状动脉(冠脉)(3DRC)造影导管和Judkins右冠脉(JR)造影管在右冠脉造影中的安全性及可行性。方法 417例患者中分别采用3DRC导管和JR造影导管作右侧冠脉造影,两组进行比较右冠脉造影X线曝光时间、右冠脉造影成功率等。结果 3DRC组右侧冠脉造影成功率99.0%,JR组成功率为96.8%;右冠造影X线曝光时间:3DRC组为(2.5±0.8)min,JR组为(2.9±1.5)min,两组差异有统计学意义。结论在右侧冠脉造影中3DRC导管优于传统的JR造影导管。     

Percutaneous technique for the reduction of knotted coronary catheters

During coronary angiography knotting of a coronary catheter is a recognised complication. It commonly results through excessive manipulation of a catheter in an attempt to engage the right coronary artery. Although simple manoeuvres of the catheter can often result in resolution of a kink, tighter knots may not be amenable to such measures. There is, however, little published material regarding its best management. We present five cases of cardiac catheterisation complicated by catheter knotting and present a novel percutaneous technique for their reduction.     

How long can a coronary reperfusion catheter be placed in acute coronary occlusion following failed transluminal coronary angioplasty? A case report

A coronary reperfusion catheter (CRC) is designed to preserve antegrade coronary flow when abrupt coronary closure occurs during percutaneous transluminal coronary angioplasty (PTCA). Insertion of the catheter to an occluded coronary artery for a few hours has been reported to be effective for myocardial salvage: however, it is unknown how long the catheter can be kept in place without causing extension of myocardial ischemia. The authors experienced a case in which the CRC was kept in place for twenty-four hours for anticoagulant therapy of an occluded coronary artery following failure of PTCA. This case suggests that adequate anticoagulant therapy can prolong the period during which a CRC can be kept in place if emergency coronary bypass surgery cannot be performed immediately after failure of coronary angioplasty.     

Percutaneous transluminal coronary angioplasty using a steerable guiding catheter: a new technique

A new type of steerable guiding catheter is described for use in percutaneous transluminal coronary angioplasty (PTCA). It is simple to use and externally steerable. The catheter incorporates a steering system by means of which the catheter tip can be made to assume the form of either a right or left Judkins catheter or to be fixed in any intermediate configuration, entirely through external manipulation. We used this new guiding catheter to perform PTCA on 15 patients. Single lesions were found in the left anterior descending branch in seven patients, in the right coronary artery in four, and in the circumflex artery in two, whereas stenosis of a coronary bypass graft was found in two patients. Angioplasty was successful in all cases. There were no complications, during either the procedure or the postoperative hospitalization. The steerable guiding catheter described here may prove useful for PTCA in cases where a conventional catheter cannot be placed accurately or in cases with multi-vessel coronary disease.     

Long-tip guiding catheter: Successful and safe for left coronary artery angioplasty

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150–180°) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, ～20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

Improved catheter for regional coronary sinus flow and metabolic studies

An improved coronary sinus catheter has been developed whose enhanced flexibility facilitates catheterization of the great cardiac vein. It allows simultaneous thermodilution measurement of blood flow in the great cardiac vein and proximal coronary sinus, easy withdrawal of blood from both sites and bipolar atrial pacing from the proximal coronary sinus. The accuracy of flow measurement with this catheter has been validated by in vitro testing, and the catheter has been used successfully in eight patients. The advantages of this improved catheter over the existing coronary sinus thermodilution catheter are discussed.     

Outcome after major dissection during coronary angioplasty using the perfusion balloon catheter

Coronary artery dissection is an infrequent but serious complication of coronary angioplasty that can lead to periprocedural vessel occlusion, emergency bypass surgery, myocardial infarction or death. Recently, a perfusion balloon catheter was developed that permits passive perfusion of blood through the central lumen of the catheter. It enables prolonged balloon inflations to be performed and has been used to provide distal blood flow after coronary occlusion. To evaluate the effectiveness of the perfusion balloon catheter in patients with major coronary dissections, 36 consecutive patients treated with the perfusion balloon catheter were compared with 46 consecutive patients treated before its availability. The 2 groups were similar in terms of clinical, angiographic and initial procedural characteristics. Use of the perfusion balloon catheter permitted a significantly longer inflation than standard balloon inflation (average 18 +/- 5 min). Angiographic success was significantly greater with the perfusion balloon catheter (84 vs 62% for conventional therapy), whereas complications were markedly reduced (48 vs 78%). With the perfusion balloon catheter there were fewer deaths (2 vs 6%), myocardial infarctions (14 vs 40%) and emergency bypass operations (11 vs 25%). The findings of this retrospective comparison demonstrate that the perfusion balloon catheter is effective for the management of major dissections after coronary angioplasty. The use of the perfusion balloon catheter should be considered when a major coronary dissection occurs and when emergency bypass surgery is contemplated.