This document discusses techniques for optimizing guide catheter support during percutaneous coronary interventions (PCIs), especially for surgically bypass graft (SVG) procedures which pose additional challenges. It describes how inadequate guide catheter support can lead to procedural failure. Several options are presented to improve support, including use of buddy wires, lesion preparation, distal anchor balloons, guide catheter extensions, and coaxial "mother-and-child" guide systems like the GuideLiner which allows deep intubation and staged procedures. The GuideLiner is highlighted as a versatile option that can be customized to different scenarios to maximize support and guidewire backup.

1. Optimization of Guide Catheter Support: What are my Options? David Meerkin Director of Experimental Cardiology Shaare Zedek Medical Center Jerusalem

7. Distal anchor balloon – JR4 guide Balloon inflated in distal vessel Guide locked in position allowing increased force on stent before displacement Need  7F Stent catheter advanced through proximal obstruction

9. Support from conventional JR4 guide JR4 guide limited support from contact with opposite aortic wall

10. Guide catheter backing out resistance to stent passage causes guide to back out –backup is lost as guide comes away from coronary osteum & aortic wall

12. Mechanisms of increasing backup with guide catheter extension Shape change of JR4 into ‘Amplatz Left’ shape increases contact aorta increasing support Deep intubation adds greatly increases contact within coronary artery greatly increasing support Shape change of guide Deep intubation of coronary

14. Coaxial “mother and child” guide extension with rapid exchange convenience Guide Extension

16. Deployment Tip of GuideLiner deployed into RCA Guide catheter positioned at ostium of RCA GuideLiner advanced distally up to 10cm into vessel

18. Distal anchor to insert Guideliner, staged stent insertion Balloon inflated in distal vessel Guideliner advanced through proximal obstruction Guide locked in position allowing increased force on Guideliner before displacement 6F 1. 2. 3. Anchor balloon removed after Guideliner crossing Stent advanced without resistance within Guideliner catheter

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

20. Guideliner assisted proximal then distal stenting Guideliner increases support to allow stent advancement into proximal lesion stent undeployed stent expanded opens proximal vessel Guideliner advanced through deployed stent allowing access to distal vessel

26. Versions Model Size Guide Catheter Compatibility GuideLiner I.D. RX Length Working Length 5571 6F (5-in-6) 6F I.D. ≥ 0.070” (1.78mm) 0.056” (1.42mm) 20 cm 135 cm 5572 7F (6-in-7) 7F I.D. ≥ 0.078” (1.98mm) 0.062” (1.57mm) 20 cm 135 cm 5573 8F (7-in-8) 8F I.D. ≥ 0.088” (2.24mm) 0.071” (1.80mm) 20 cm 135 cm