This document discusses methods for optimizing backup support when performing percutaneous coronary interventions (PCIs). It describes how guide catheters can lose backup support as they are withdrawn from the coronary ostium and aorta. Solutions proposed include using anchor balloons, buddy wires, and lesion preparation to improve friction. Guide catheter extensions are highlighted as an effective way to increase backup support, enable deeper seating, improve force transmission, and allow proximal-to-distal stenting by bypassing tortuous vessels or deployed stents. Data is presented showing high success rates for stent delivery with extensions. In conclusion, guide extensions are a useful tool for overcoming vessel resistance and limitations of poor guide support to enable procedures that may otherwise not be possible

1. Optimising back up support
Douglas Fraser
Manchester Royal Infirmary
UK

2. Guide catheter backing out
Backup achieved by contact As guide backs out –backup
with coronary osteum and aorta lost as guide comes away from
coronary osteum & aortic wall
JR4

3. Solutions
• Poor backup support guide anchor balloon
deep seating large bore guide
• Tortuousity support wire
buddy
wire
• Friction lesion preparation
lower profile
stent
Ballooning / buddy wire frequently only option without
changing guide
→ Guide catheter extension
use within 6F guide over wires already in place

7. HEARTRAIL
GUIDELINER

8. How Guide catheter extension helps
1) ↑back up support
shape change
extra deep seating
2) Cross obstruction easier than a stent
more flexible / smoother
pulling down
3) Proximal to distal stenting
crosses deployed stents with ease

9. Extension ↑↑ force transmission
Shape modification Deep intubation ↑↑ Force
↑ contact aorta ↑ contact coronary transmission
bypass tortuousity
Improved coaxial
Amplatzing alignment

10. only
only
• 2cm intubation equates to 8F guide Takahashi CCI 2004

11. Balloon / stent delivery CTO
CCI in press 2010 Mamas Ordoubadi Fraser

12. More difficult stent delivery

13. Extension crosses tortuousity
easier than stent

15. Pull catheter in over balloon inflated
distal lesion

16. Pulling is less traumatic than pushing
Wire re-centered

19. Conventional anchor

20. Severe proximal and distal disease
Severe proximal
disease causes
pressure damping
prevents coronary
intubation
Distal disease cannot
be reached

21. Assisted proximal then distal stenting
Stent advanced into Extension advanced Stent advanced into
proximal disease through deployed stent distal vessel with ease
= obstruction crossed

22. Getting out of
trouble 6F
• Wire exchange

23. • Guideliner proximal → distal stenting

25. Bypass graft PCI

26. Extend tip to cannulate osteum
• Heartrail 5in6

27. Backup aortic valve

29. Proximal → Distal stenting

31. Success stent delivery vs intubation
22 depth/cm 37 cases
20
18
16
Intubation depth
14
12
10 Failure
8 Success
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Case
Eurointervention 2009;5 (2) 265-71 Mamas Ordoubadi Fraser

32. Balloon / stent delivery 175 cases
• Non CTO lesions n=145
– Prior failure 46%
– Upfront use 54%
– Success 94%
– RCA 55% LAD / Cx / VG 15%
• CTO lesions n=30
– wire cross success 4/15 cases
– balloon / stent cross success all 15 cases
• Complications 2 cases dissection

33. Conclusion
• Stent (equipment ) delivery → overcome vessel /
lesion resistance
• Support guides, deep intubation often useful
• Guide extensions very useful
– ↑↑ force transmission
– cross obstructions easier than stents
– can be pulled down the vessel
– enable proximal to distal stenting
– very useful vein graft PCI
• Overcome limitations of poor guide support
• Get you out of trouble, enable procedures
otherwise not possible

36. Comparison
• Both highly effective, atraumatic
• Can use within standard guide in situ without moving wire
Heartrail
• Air embolism
• Removal often disturbs undocked wires
• Can only extent stent 8cm beyond tip
Guideliner
• Rapid exchange convenience
• No air embolism
• Large stents, stents on secondary wires catch at
metal collar – wire wrap

37. CCI 72:222–227 (2008)
KIWAMI 4Fr. Straight Prototype
I.D. 0.050” (1.27 mm) O.D. 4 Fr. (1.43 mm) Length 120cm

38. • 6F ID 0.51
– equivalent 4F HR
• 7F ID 0.59
– equivalent 5F HR