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Rare complications of Guideplus guide-extension catheter during complex percutaneous coronary intervention

  • Mitsuhiko Shoda
    Affiliations
    Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan
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  • Hiroyuki Yamamoto
    Correspondence
    Corresponding author at: Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, 3-264 Kamiya-cho, Himeji, Japan.
    Affiliations
    Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan

    Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Japan
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  • Yoshiro Tsukiyama
    Affiliations
    Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan

    Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Japan
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  • Hiroya Kawai
    Affiliations
    Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan

    Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Japan

    Department of Exploratory and Advanced Research in Cardiology, Kobe University Graduate School of Medicine, Kobe, Japan
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  • Tomofumi Takaya
    Affiliations
    Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan

    Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Japan

    Department of Exploratory and Advanced Research in Cardiology, Kobe University Graduate School of Medicine, Kobe, Japan
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Open AccessPublished:August 22, 2022DOI:https://doi.org/10.1016/j.jccase.2022.08.006

      Abstract

      Guide-extension catheters (GECs) are effective in providing reinforced backup support and coaxial alignment, leading to successful complex percutaneous coronary intervention (PCI). However, several GEC-associated complications have been reported, including coronary injuries, thrombotic events, and GEC fractures. The Guideplus GEC (Guideplus II ST; Nipro, Osaka, Japan) has a higher crossability due to its unique hydrophilic-coated soft cylinder, which is frequently used in complex PCI for diffuse, tortuous, and heavily calcified lesions. We describe two cases of Guideplus GEC-associated complications during complex PCI: Case 1 with a radiopaque marker dislodgement and Case 2 with a stent dislodgment. In both cases, the Guideplus GEC was used within 7-Fr guiding catheters, employing the mother-and-child technique. A large inner-catheter gap between these catheters caused by a positioning bias due to arterial bends (the aortic arch in Case 1 and brachiocephalic arterial bends in Case 2) may have caused these complications due to its interference with coronary devices (the trapping balloon in Case 1, and the scoring balloon in Case 2). Early cognition and management of these potential Guideplus GEC-associated complications are important to prevent further deterioration.

      Learning objectives

      The Guideplus guide-extension catheter (GEC) with a hydrophilic-coated soft cylinder can deliver coronary devices to complex lesions owing to its high crossability. However, delivering coronary devices with the Guideplus GEC should be carefully performed because a large inner-catheter gap between Guideplus GEC and a guiding catheter may occur if a proximal port of the Guideplus GEC is located at an arterial bend. In such settings, Guideplus GEC-associated complications must be carefully observed, including radiopaque marker dislodgement and stent dislodgement.

      Keywords

      Introduction

      Complex percutaneous coronary intervention (PCI) for anatomically challenging diffuse, tortuous, and calcified lesions is increasingly being performed due to advancements in PCI techniques and devices. Guide-extension catheters (GEC) are effective in providing reinforced backup support and coaxial alignment, facilitating successful PCI [
      • Fabris E.
      • Kennedy M.W.
      • Di Mario C.
      • Sinagra G.
      • Roolvink V.
      • Ottervanger J.P.
      • Van't Hof A.W.J.
      • Kedhi E.
      Guide extension, unmissable tool in the armamentarium of modern interventional cardiology.A comprehensive review.
      ,
      • Duong T.
      • Christopoulos G.
      • Luna M.
      • Christakopoulos G.
      • Master R.G.
      • Rangan B.V.
      • Roesle M.
      • Banerjee S.
      • Brilakis E.S.
      Frequency, indications, and outcomes of guide catheter extension use in percutaneous coronary intervention.
      ]. The Guideplus GEC (Guideplus II ST; Nipro, Osaka, Japan) comprises a hydrophilic-coated soft cylinder, 250 mm in length and with a 1.33-mm (0.052-inch) inner diameter, and a unique port with a radiopaque marker located at the transition of the port and cylinder, which has high crossability to heavily calcified lesions and compatibility with a ≥6-Fr guiding catheter [
      • Tsukui T.
      • Sakakura K.
      • Taniguchi Y.
      • Yamamoto K.
      • Wada H.
      • Momomura S.I.
      • Fujita H.
      Comparison of the device performance between the conventional guide extension catheter and the soft guide extension catheter.
      ]. We present two cautionary cases of Guideplus GEC-associated complications, namely a radiopaque marker dislodgment and a stent dislodgment, during complex PCI. Informed consent to publish the cases and any accompanying images was obtained from the patients.

      Case 1

      A 64-year-old woman undergoing hemodialysis was admitted with persistent chest pain and diagnosed with inferior ST-segment elevation acute myocardial infarction. Her hemodynamic condition was stable; her blood pressure and heart rate were 114/68 mmHg and 58 beats/min, respectively. Urgent coronary angiography (CAG) showed occlusion of the proximal right coronary artery (RCA) as the culprit lesion and a heavily calcified stenosis in the proximal left anterior descending artery (LAD) as a non-culprit lesion. Primary PCI for the proximal RCA was successfully performed, with optimal results of coronary flow of Thrombolysis in Myocardial Infarction grade 3. After an uneventful clinical course, a scheduled PCI for the proximal LAD was performed using a 7-Fr EBU3.5 guiding catheter (Launcher; Medtronic Inc., Minneapolis, MN, USA) via the right femoral artery (Fig. 1A ). Although successful wiring of the main LAD and the second diagonal branch was achieved, PCI devices, such as small-sized balloons and intravascular ultrasound (IVUS) (Altaview™; Terumo, Tokyo, Japan), could not reach the target lesion, even with Guideplus GEC support. Thereafter, rotational atherectomy was successfully performed on a Rotawire Floppy (Rota Wire™, Boston Scientific, Natick, MA, USA) with a 1.5-mm burr without Guideplus GEC support. IVUS was repeated under Guideplus GEC support to confirm intravascular condition. Then, a Rotawire Floppy was exchanged with a 0.014-inch guidewire (Runthrough® NS; Terumo) using a microcatheter (ASAHI Caravel MC; ASAHI Intecc, Aichi, Japan). We tried to retrieve the microcatheter using a TRAPPER™ trapping balloon (Boston Scientific); however, a slight resistance was perceived during the procedure, and fluoroscopy revealed that the trapping balloon did not completely advance into the 7-Fr guiding catheter, potentially due to an inner-catheter gap between the 6-Fr Guideplus GEC and the 7-Fr guiding catheter (Fig. 1B-C). Consequently, we inflated the trapping balloon advanced to hold the Runthrough® NS wire; then, the microcatheter was removed. Subsequently, a 2.5/15-mm cutting balloon (WOLVERINE™; Boston Scientific) was delivered to the lesion under the Guideplus GEC support; however, an unknown foreign body became attached to the cutting balloon and migrated into the mid-LAD (Fig. 2A ). After withdrawing both devices, we attempted to deliver a small balloon to entrap the foreign body; however, it advanced in a distal direction (Fig. 2A). Thereafter, we performed balloon angioplasty for the culprit lesion and successfully retrieved the foreign body using a 5-mm snare (Amplatz Goose Neck™ snare kit, Medtronic) in a 7-Fr GuideLiner® V3 GEC (Teleflex, Wayne, PA, USA) (Fig. 2B). Finally, additional balloon angioplasty with a cutting balloon and subsequent implantation of a drug-eluting stent (DES) was successful without further complications.
      Fig. 1
      Fig. 1Mechanism of the Guideplus guide-extension catheter damage. (A) Coronary angiography shows heavily calcified stenoses in the mid-left anterior descending artery and the second diagonal branch (yellow dotted lines). (B) The TRAPPER™ trapping balloon could not advance into the 7-Fr guiding catheter from the proximal port of the Guideplus guide-extension catheter (GEC). (C) The softness of the Guideplus GEC results in a large inner-catheter gap between the two catheters when a proximal port of the Guideplus GEC is located at the aortic arch bend. During withdrawal of the microcatheter, unexpected force (red arrows) could potentially place external stress on the radiopaque marker of the Guideplus GEC, resulting in its dislodgement.
      Fig. 2
      Fig. 2Radiopaque marker dislodgement. (A) Fluoroscopy shows the distal migration of a foreign body (yellow arrow) as a cutting balloon (dotted line) advances into the left anterior descending artery (LAD) over the 0.014-in. guidewire. (B) A snare catheter (dotted line) with 7-Fr GuideLiner® V3 GEC support is advanced to the distal LAD, where the dislodged radiopaque marker (yellow arrow) of the Guideplus guide-extension catheter (GEC) is located, and successfully grasps it. The snare catheter and 0.014-in. guidewire are simultaneously pulled back into the GuideLiner® V3 GEC and completely retrieved. (C-F) Findings of the retrieved Guideplus GEC. (C) Deformed proximal port of Guideplus GEC. (D) Comparison of the Guideplus GEC in Case 1 and an unused one. (E) Fluoroscopy reveals the Guideplus GEC without a proximal radiopaque marker. (F) The dislodged radiopaque marker of the Guideplus GEC was retrieved using the snare catheter.
      After the PCI, a fluoroscopic evaluation confirmed that the unknown foreign object was the migrated radiopaque marker of the Guideplus GEC; thus, radiopaque marker dislodgement was confirmed (Fig. 2C-F). The patient was discharged 2 days after the PCI, and an uneventful clinical course was observed for one year.

      Case 2

      A 74-year-old man with a history of hypertension, type 2 diabetes mellitus, and chronic kidney disease presented with exertional angina pectoris. CAG showed calcified stenosis in the proximal LAD (Fig. 3A ). A scheduled PCI for the calcified lesion was performed using a 7-Fr EBU3.5 guiding catheter via the right radial artery. Rotational atherectomy with a 1.5-mm and subsequent 2.0-mm burr was successfully performed, and a 3.0/13-mm scoring balloon catheter (Aperta NSE; Nipro) was delivered under 6-Fr Guideplus GEC support. The Aperta NSE balloon advanced into the Guideplus GEC with a little resistance. After balloon angioplasty with adequate expansion, delivery of a 3.5/18-mm DES (Orsiro; Biotronik AG, Bülach, Switzerland) to the culprit lesion was attempted; however, the DES could not pass into the Guideplus GEC, even using a careful approach under fluoroscopic guidance. The Guideplus GEC was pulled backward while holding stent balloon to insert the DES into the Guideplus GEC; however, fluoroscopy showed that this resulted in the stent being stripped off the stent-balloon platform (Fig. 3B-C). We cautiously withdrew the devices and visually observed that the Guideplus port was fractured, and the stent was dislodged from the stent balloon (Fig. 3D-G). A new DES (Orsiro) was subsequently inserted into a new 6-Fr Guideplus GEC outside the patient's body, and this combination reached the culprit lesion. The DES was successfully implanted without any complications. After the PCI, the patient was free from angina symptoms for 8 months.
      Fig. 3
      Fig. 3Stent dislodgement. (A) Coronary angiography shows heavily calcified stenosis in the left anterior descending artery (yellow dotted line). (B) A 3.5/18-mm drug-eluting stent (DES) (orange dotted line) is unable to advance into the Guideplus guide-extension catheter (GEC) from the proximal port of the Guideplus GEC. (C) The Guideplus GEC is pulled backward to insert the DES into the Guideplus GEC; fluoroscopy reveals that the stent was stripped off the stent-balloon platform (blue dotted line). (D) The fractured proximal port of the Guideplus GEC in Case 2. (E-G) The dislodged stent before (E) and after (F-G) inflates the stent balloon outside the body.

      Discussion

      The Guideplus GEC, which has excellent crossability and compatibility with a ≥6-Fr guiding catheter due to its soft cylinder, hydrophilic coating, and unique-shaped entrance port, is reportedly effective for complex PCIs [
      • Tsukui T.
      • Sakakura K.
      • Taniguchi Y.
      • Yamamoto K.
      • Wada H.
      • Momomura S.I.
      • Fujita H.
      Comparison of the device performance between the conventional guide extension catheter and the soft guide extension catheter.
      ]. Currently, complex PCI for calcified lesions is often performed using the ≥7-Fr system because of the compatibility for atherectomy devices, and Guideplus GEC is usually used with the mother-and-child technique (6-Fr Guideplus GEC in ≥7-Fr guiding catheter). Various GEC-associated complications have been reported, including coronary artery injury, GEC fractures, thrombotic events, and stent damage; meanwhile, Guideplus GEC-associated complications are rarely reported [
      • Chang Y.C.
      • Fang H.Y.
      • Chen T.H.
      • Wu C.J.
      Left main coronary artery bidirectional dissection caused by ejection of guideliner catheter from the guiding catheter.
      ,
      • Waggoner T.
      • Desai H.
      • Sanghvi K.
      A unique complication of the GuideZilla guide extension support catheter and the risk of stent stripping in interventional & endovascular interventions.
      ,
      • Waterbury T.M.
      • Sorajja P.
      • Bell M.R.
      • Lennon R.J.
      • Mathew V.
      • Singh M.
      • Sandhu G.S.
      • Gulati R.
      Experience and complications associated with use of guide extension catheters in percutaneous coronary intervention.
      ]. In the present cases, Guideplus GEC-associated complications involving radiopaque markers and stent dislodgement occurred. These cases had one common feature: the 6-Fr Guideplus GEC, with an outer diameter of 0.061 and 0.069 in., respectively at distal and proximal parts, was used within a 7-Fr guiding catheter (inner diameter, 0.081 in.), which can theoretically lead to a maximal inner-catheter gap of 0.020 in. distally and 0.012 in. proximally, between these devices.
      In Case 1, a TRAPPER™ trapping balloon might have been inflated within the gap between the Guideplus GEC and the guiding catheter, which could have caused deformation of the proximal port of the Guideplus GEC, leading to proximal radiopaque marker dislodgement. Very few cases of GEC-associated radiopaque marker dislodgement during PCI have been reported. A technique using a small balloon has been reported for retrieving migrated objects [
      • Paulus B.M.
      • Fischell T.A.
      Retrieval devices and techniques for the extraction of intravascular foreign bodies in the coronary arteries.
      ]; however, in our case, the use of a small-sized balloon unfortunately advanced the dislodged radiopaque marker more distally. Conversely, retrieval with a snare catheter was successful. Additionally, a rare case of ring marker dislodgement of a GuideLiner® V3 GEC, where a coronary stent was implanted to trap the dislodged ring marker between the stent and vessel wall, has been reported [
      • Papayannis A.C.
      • Michael T.T.
      • Brilakis E.S.
      Challenges associated with use of the GuideLiner catheter in percutaneous coronary interventions.
      ]. However, considering the size of the present migrated Guideplus radiopaque marker, this technique should be avoided because of the potential risk of coronary perforation.
      In Case 2, deformation of the proximal port of Guideplus GEC, which might have been damaged by the scoring balloon before DES delivery, was observed. This fractured Guideplus proximal port could have hooked onto the coronary stent during delivery and stripped it off the stent-balloon platform. GEC-associated stent damage has been reported [
      • Papayannis A.C.
      • Michael T.T.
      • Brilakis E.S.
      Challenges associated with use of the GuideLiner catheter in percutaneous coronary interventions.
      ]; however, Guideplus GEC-associated stent damage has not yet been described. It is important to note that the GEC entrance located at bent sites could be easily damaged, which may induce stent dislodgement; early recognition of this complication may prevent its further exacerbation.
      Comparison of GECs available in Japan is listed in Online Fig. 1. The Guideplus GEC is useful for reaching distal lesions because of its special profile of a tapered cylinder with a distal outer diameter of 1.55 mm and proximal outer diameter of 1.76 mm. However, considering the soft material of the Guideplus cylinder, a positioning bias of Guideplus GEC could be predisposed to these complications when the proximal port of the Guideplus GEC is located at the arterial bends, for example, at the aortic arch in case of PCI via the femoral artery or at the brachiocephalic artery in case of PCI via the right radial artery. This is not simple due to the patient's physique limitations and other factors affecting the positional relationship. Therefore, we should avoid using trapping balloons and cautiously advance coronary devices, such as scoring balloons, cutting balloons, and coronary stents, into the Guideplus GEC under fluoroscopic guidance to prevent these complications, especially in cases wherein a proximal port of the Guideplus GEC is located at arterial bends. Furthermore, another GEC with a long cylinder or compatible diameter to the guiding catheter could be used to reduce the inter-catheter gap in such cases, if applicable (Online Fig. 1).
      While the Guideplus GEC is effective in complex PCI, Guideplus GEC-associated complications should be recognized, particularly in cases where the proximal port of the Guideplus GEC is located at the arterial bends.
      Online Fig. 1
      Online Fig. 1Comparison chart of guide-extension catheters.

      Declaration of competing interest

      The authors declare that there is no conflict of interest.

      Acknowledgments

      None.

      Funding statement

      None.

      Patient consent statement

      Informed consent was obtained from the patients for publication of the case and accompanying images.

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