Catheterization and Cardiovascular Diagnosis 2598.1 00 (1992)
Percutaneous Transluminal Coronary Angioplasty Through 4 French Diagnostic Catheters V.P. Moles, MD, B. Meier, MD, P. Urban, MD, F. de la Serna, MD, and A.K. Pande, MD The use of 4 French (4F) diagnostic catheters as guiding catheters for coronary angioplasty using fixed-wire balloons in 2 patients with a stenosis of the right and left anterior descending coronary artery, respectively, is reported. Key words: PTCA, 4F catheterization, guiding catheters
INTRODUCTION
A 4F angiographic catheter, with an internal lumen of 0.040 inch, has recently been introduced for coronary angiography in adults. Based on previous experience with angioplasty through small catheters [ 1-41, we started to use 4F diagnostic catheters for coronary angioplasty (PTCA) in conjunction with fixed-wire balloon catheters. The first 2 cases are reported. CASE 1
A 48-yr-old man was admitted to the intensive care unit because of an inferior acute myocardial infarction. He underwent coronary angiography six days later, which revealed an ejection fraction of 55%, a reasonably well preserved function of the posterior wall of the left ventricle, and a short significant stenosis of the proximal right coronary artery (RCA) (presumably the recanalized occlusion) (Fig. 1). The left coronary artery was normal. During the same session, PTCA was done through a 4F right Judkins diagnostic catheter (Cordis) with an ACE 3.0 mm fixed-wire balloon (Scimed). To improve vessel visualization while the balloon was in the lesion, a small caliber 2 ml glass syringe was used. During balloon inflation, a transient second degree atrioventricular block appeared (Fig. 2). The angiographic result was good (Fig. 1). It was impossible to withdraw the balloon through the 4F catheter. Both catheters were removed en bloc and the connector of the balloon catheter was broken off, to separate the 2 catheters. The 4F catheter was then reintroduced for the final angiogram. The patient was discharged the next day.
months prior to admission. A Thallium stress test was positive -for ischemia. Coronary angiography was performed through a femoral approach (4F sheath), with 4F pigtail and left and right Judkins catheters. It revealed an ejection fraction of 43%, akinesia of the anterior wall of the left ventricle, and an eccentric subtotal stenosis in the mid left anterior descending coronary artery (Fig. 3A). During the same session, PTCA was done through the diagnostic 4F left Judkins catheter with a fixed-wire ACE 2.5 mm (Scimed) balloon. Figure 3B shows that adequate vessel visualization was possible even with the balloon in place. The balloon was inflated to a maximum of 16 bar, at which pressure it ruptured after 15 seconds. Again, the 4F catheter had to be removed from the patient to withdraw the balloon and reintroduced for the final angiogram. The result was satisfactory (Fig. 3A). The patient was discharged the next morning. DISCUSSION The rationale of performing PTCA through 4F catheters is twofold. First, the small arterial puncture hole used for the diagnostic study, which at our center is frequently performed with 4F catheters, has not to be enlarged for an immediately ensuing PTCA. Second, the diagnostic catheter serves as guiding catheter, which is cost efficient. The main problem of PTCA through small catheters is the retrieval of the balloon at the end of the procedure. Winging of the balloon frequently prevented balloon
From the Cardiology Center, University Hospital, Geneva, land.
Switzer-
CASE 2
Received February 28. 1991; revision accepted June 20, 1991.
A 63-yr-old man was admitted for coronary angiography. He had had an anterior myocardial infarction 7
Address reprint requests to Dr. Bernhard Meier, Cardiology Center, University Hospital, 121 I Geneva 4, Switzerland.
0 1992 Wiley-Liss, Inc.
4F Coronary Angioplasty
99
w
Fig- 1. PTCA through 4F catheter (cordis). TOP: short lesion in the Proximal Part Of the RCA (arrow). Middle: 3 mm ACE balloon (Scimd) inflated in the lesion. Simultaneous contrast fnedium injection to ascertain correct balloon position. Bottom: final resuit.
withdrawal through the first generation of 6F catheters used for PTCA [3]. With the new generation ACE balloons featuring a slippery coating, retrieving the balloon through 6F catheters with a lumen of 0.050 inch or larger has been possible in 90% of cases with balloon sizes up to 4.0 mm. With 4F catheters, balloon withdrawal was impossible for both the intact 3.0 mm and the ruptured 2.5 mm balloon. However, it was possible in most patients in our subsequent experience for balloons up 3.0 mm. Although the impossibility to remove the balloon without damaging it was of no importance in these two cases, it can represent a problem if an unsatisfactory result becomes apparent only during the final angiogram once the balloon catheter has been discarded. In this case, a new balloon would have to be used. Other drawbacks are that the intrinsic back up of small catheters is inferior to that of large catheters and the small lumen makes sufficient vessel visualization more
Fig. 2. Transient second degree atrioventricular block during balloon inflation. Simultaneous surface (leads I and II) and intracoronary (ic) ECG (5) recording with the balloon catheter placed in the lesion (distal extremity of the wire in the mid right coronary artery, at the atrioventricular groove). The first P wave (arrow) is blocked which is more readily apparent from the intracoronary ECG. Even the atrial repolarization (small arrow) can be discerned in the lntracoronary lead.
difficult. However, small catheters can generally be advanced deeply into the coronary artery thereby providing adequate support and vessel opacification can be improved by using small caliber syringes. Finally, only fixed-wire balloons can be used. If a perfusion balloon or a coronary stent becomes necessary the 4F system has to be replaced by a larger catheter and the lesion renegotiated. Technical problems may be quite common with 4F catheters but most of them are amendable by upgrading to a larger catheter without untoward effect to the patient. This produces no additional cost compared to an angioplasty started with such a catheter. The practice of 4F PTCA for selected patients should reduce the risk of puncture site complications and expenses. At present, this technique has to be reserved for straightforward cases and only further experience will
100
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Fig. 3. A: Subtotal left anterior descending coronary artery stenosis (arrow), before (top) and after (bottom) PTCA through 4F Catheter. 8: Top: 2.5 ACE balloon inserted through 4 French catheter and Inflated at 16 bar. Bottom: Adequate visualization of coronary artery through 4F catheter with the balloon across the lesion (wire tip of balloon catheter Indicated by arrow).
determine whether it is reasonable to attempt more complex lesions. REFERENCES I . Salinger MH, Kern MJ: First use of a 5 French diagnostic catheter for percumeous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1989:18:276-278. 2. Meier B: Technique of coronary angioplasty, In: Meier B (ed): “lnterventional Cardiology.” Toronto: Hogrefe & Huber Publishers, 1990, pp 45-70.
3. Villavicencio R, Urban P, Muller T, Favre J , Meier B: Coronary balloon angioplasty through diagnostic 6 French catheters. Cathet Cardiovasc Diagn 1991;22:56-59. 4. Kern MJ, Talley D, Deligonul U, Serota H, Aguirre F. Gudipati Ch, Ring M, Joseph A, Yusman ZA. Kulick D, Salinger M: Preliminary experience with 5 and 6 French diagnostic catheters as guiding catheters for coronary angioplasty . Cathet Cardiovasc Diagn 1991;22:60-63. 5 . Meier B, Killisch JP, Adatte JJ. Casalini P. Rutishauser: Intrakoronares Elektrokardiogramm w&hrend transluminaler Koronarangioplastie. Schweiz Med Wchenschr 1985;115:1590-1593.
Percutaneous Transluminal Coronary Angioplasty Through 4 French Diagnostic Catheters V.P. Moles, MD, B. Meier, MD, P. Urban, MD, F. de la Serna, MD, and A.K. Pande, MD The use of 4 French (4F) diagnostic catheters as guiding catheters for coronary angioplasty using fixed-wire balloons in 2 patients with a stenosis of the right and left anterior descending coronary artery, respectively, is reported. Key words: PTCA, 4F catheterization, guiding catheters
INTRODUCTION
A 4F angiographic catheter, with an internal lumen of 0.040 inch, has recently been introduced for coronary angiography in adults. Based on previous experience with angioplasty through small catheters [ 1-41, we started to use 4F diagnostic catheters for coronary angioplasty (PTCA) in conjunction with fixed-wire balloon catheters. The first 2 cases are reported. CASE 1
A 48-yr-old man was admitted to the intensive care unit because of an inferior acute myocardial infarction. He underwent coronary angiography six days later, which revealed an ejection fraction of 55%, a reasonably well preserved function of the posterior wall of the left ventricle, and a short significant stenosis of the proximal right coronary artery (RCA) (presumably the recanalized occlusion) (Fig. 1). The left coronary artery was normal. During the same session, PTCA was done through a 4F right Judkins diagnostic catheter (Cordis) with an ACE 3.0 mm fixed-wire balloon (Scimed). To improve vessel visualization while the balloon was in the lesion, a small caliber 2 ml glass syringe was used. During balloon inflation, a transient second degree atrioventricular block appeared (Fig. 2). The angiographic result was good (Fig. 1). It was impossible to withdraw the balloon through the 4F catheter. Both catheters were removed en bloc and the connector of the balloon catheter was broken off, to separate the 2 catheters. The 4F catheter was then reintroduced for the final angiogram. The patient was discharged the next day.
months prior to admission. A Thallium stress test was positive -for ischemia. Coronary angiography was performed through a femoral approach (4F sheath), with 4F pigtail and left and right Judkins catheters. It revealed an ejection fraction of 43%, akinesia of the anterior wall of the left ventricle, and an eccentric subtotal stenosis in the mid left anterior descending coronary artery (Fig. 3A). During the same session, PTCA was done through the diagnostic 4F left Judkins catheter with a fixed-wire ACE 2.5 mm (Scimed) balloon. Figure 3B shows that adequate vessel visualization was possible even with the balloon in place. The balloon was inflated to a maximum of 16 bar, at which pressure it ruptured after 15 seconds. Again, the 4F catheter had to be removed from the patient to withdraw the balloon and reintroduced for the final angiogram. The result was satisfactory (Fig. 3A). The patient was discharged the next morning. DISCUSSION The rationale of performing PTCA through 4F catheters is twofold. First, the small arterial puncture hole used for the diagnostic study, which at our center is frequently performed with 4F catheters, has not to be enlarged for an immediately ensuing PTCA. Second, the diagnostic catheter serves as guiding catheter, which is cost efficient. The main problem of PTCA through small catheters is the retrieval of the balloon at the end of the procedure. Winging of the balloon frequently prevented balloon
From the Cardiology Center, University Hospital, Geneva, land.
Switzer-
CASE 2
Received February 28. 1991; revision accepted June 20, 1991.
A 63-yr-old man was admitted for coronary angiography. He had had an anterior myocardial infarction 7
Address reprint requests to Dr. Bernhard Meier, Cardiology Center, University Hospital, 121 I Geneva 4, Switzerland.
0 1992 Wiley-Liss, Inc.
4F Coronary Angioplasty
99
w
Fig- 1. PTCA through 4F catheter (cordis). TOP: short lesion in the Proximal Part Of the RCA (arrow). Middle: 3 mm ACE balloon (Scimd) inflated in the lesion. Simultaneous contrast fnedium injection to ascertain correct balloon position. Bottom: final resuit.
withdrawal through the first generation of 6F catheters used for PTCA [3]. With the new generation ACE balloons featuring a slippery coating, retrieving the balloon through 6F catheters with a lumen of 0.050 inch or larger has been possible in 90% of cases with balloon sizes up to 4.0 mm. With 4F catheters, balloon withdrawal was impossible for both the intact 3.0 mm and the ruptured 2.5 mm balloon. However, it was possible in most patients in our subsequent experience for balloons up 3.0 mm. Although the impossibility to remove the balloon without damaging it was of no importance in these two cases, it can represent a problem if an unsatisfactory result becomes apparent only during the final angiogram once the balloon catheter has been discarded. In this case, a new balloon would have to be used. Other drawbacks are that the intrinsic back up of small catheters is inferior to that of large catheters and the small lumen makes sufficient vessel visualization more
Fig. 2. Transient second degree atrioventricular block during balloon inflation. Simultaneous surface (leads I and II) and intracoronary (ic) ECG (5) recording with the balloon catheter placed in the lesion (distal extremity of the wire in the mid right coronary artery, at the atrioventricular groove). The first P wave (arrow) is blocked which is more readily apparent from the intracoronary ECG. Even the atrial repolarization (small arrow) can be discerned in the lntracoronary lead.
difficult. However, small catheters can generally be advanced deeply into the coronary artery thereby providing adequate support and vessel opacification can be improved by using small caliber syringes. Finally, only fixed-wire balloons can be used. If a perfusion balloon or a coronary stent becomes necessary the 4F system has to be replaced by a larger catheter and the lesion renegotiated. Technical problems may be quite common with 4F catheters but most of them are amendable by upgrading to a larger catheter without untoward effect to the patient. This produces no additional cost compared to an angioplasty started with such a catheter. The practice of 4F PTCA for selected patients should reduce the risk of puncture site complications and expenses. At present, this technique has to be reserved for straightforward cases and only further experience will
100
Moles et al.
Fig. 3. A: Subtotal left anterior descending coronary artery stenosis (arrow), before (top) and after (bottom) PTCA through 4F Catheter. 8: Top: 2.5 ACE balloon inserted through 4 French catheter and Inflated at 16 bar. Bottom: Adequate visualization of coronary artery through 4F catheter with the balloon across the lesion (wire tip of balloon catheter Indicated by arrow).
determine whether it is reasonable to attempt more complex lesions. REFERENCES I . Salinger MH, Kern MJ: First use of a 5 French diagnostic catheter for percumeous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1989:18:276-278. 2. Meier B: Technique of coronary angioplasty, In: Meier B (ed): “lnterventional Cardiology.” Toronto: Hogrefe & Huber Publishers, 1990, pp 45-70.
3. Villavicencio R, Urban P, Muller T, Favre J , Meier B: Coronary balloon angioplasty through diagnostic 6 French catheters. Cathet Cardiovasc Diagn 1991;22:56-59. 4. Kern MJ, Talley D, Deligonul U, Serota H, Aguirre F. Gudipati Ch, Ring M, Joseph A, Yusman ZA. Kulick D, Salinger M: Preliminary experience with 5 and 6 French diagnostic catheters as guiding catheters for coronary angioplasty . Cathet Cardiovasc Diagn 1991;22:60-63. 5 . Meier B, Killisch JP, Adatte JJ. Casalini P. Rutishauser: Intrakoronares Elektrokardiogramm w&hrend transluminaler Koronarangioplastie. Schweiz Med Wchenschr 1985;115:1590-1593.
