Novel Use of GuideLiner Catheter to Perform Aspiration Thrombectomy in a Saphenous Vein Graft

Abstract

The GuideLiner catheter is a monorail “mother and child” guiding catheter extension that serves to facilitate stent delivery and is approved for providing extra support and coaxial guide engagement. While this device was primarily designed to aid in balloon and stent delivery, we describe a novel use of this catheter to aid in aspiration thrombectomy.

A 73-year-old male patient with past medical history significant for coronary artery disease status post coronary artery bypass grafting 10 years prior presented to the hospital with a non-ST segment elevation myocardial infarction. During left heart catheterization, a long thrombus was visualized in the saphenous vein graft to the obtuse marginal artery. Despite the use of Export aspiration catheter, and intracoronary nipride and abciximab, only partial thrombectomy could be performed. A 6 French GuideLiner catheter was inserted through a 6 French guide catheter and aspiration thrombectomy was performed, resulting in a successful aspiration of a two-inch-long thrombus. Our report demonstrates a novel use of a GuideLiner catheter for aspiration thrombectomy, which to our knowledge has never been described as a primary tool for this purpose.

Introduction

The GuideLiner catheter (Vascular Solutions, Inc.) is a monorail “mother and child” guiding catheter extension which primarily serves as guide back up support for complex percutaneous coronary interventions.¹ This is a case report of a successful aspiration thrombectomy performed through the GuideLiner catheter after numerous failed attempts using an Export aspiration catheter (Medtronic).

Case report

A 73-year-old man with past medical history significant for coronary artery disease (CAD) status post coronary artery bypass grafting (CABG) in 2002, chronic kidney disease status post nephrectomy, presented to the emergency department after experiencing constant substernal chest pressure associated with mild shortness of breath. He has since been diagnosed with bladder cancer with metastases to the lung and is currently on Cisplatin chemotherapy. The patient had undergone a nuclear stress test, which was negative for stress-induced ischemia, approximately five years ago and has not had any further cardiovascular workup since then. The patient’s laboratory workup was significant for a creatinine of 1.9, which is at his baseline, and elevated troponin of 1.25. His EKG showed normal sinus rhythm with a first-degree atrioventricular block and non-specific ST-T changes. The patient was continued on an aspirin and beta blocker regimen with the addition of enoxaparin 1 mg/kg SQ BID. Nephrology consult was obtained for appropriate risk stratification for the possibility of contrast-induced nephropathy. On the following day, the patient was taken to the catheterization laboratory for a left heart catheterization (LHC). Findings of the LHC included a patent left main coronary artery, 100% occlusion of left anterior descending artery in its mid portion, 100% occlusion of the left circumflex artery in its midportion, and a greater than 70% stenosis in the mid portion of the right coronary artery. The left internal mammary artery (LIMA) to the LAD was patent. The saphenous vein graft (SVG) to the diagonal artery was not visualized and appeared to be totally occluded. The SVG to the circumflex obtuse marginal (OM) system jump graft had a long clot filling 99% of the jump graft to the distal OM branch (Figure 1). 

The intervention was performed using a 6 French Judkins right (JR)4 guide catheter to engage the SVG to the OM, followed by using a Choice floppy guide wire (Boston Scientific) to cross the lesion. Aspiration thrombectomy with Export aspiration catheter followed, with multiple, unsuccessful attempts. Only minimal or partial thrombus was aspirated. Intracoronary nipride as well as abciximab was injected, followed by an abciximab drip. Then, a 6 French GuideLiner catheter was inserted through a 6 French guide catheter, with the distal end positioned deep in the SVG, just a few millimeters from the clot, with the proximal portion still within the guide catheter. Aspiration was performed through the GuideLiner and the catheter, with a 20 cc syringe applied to a stopcock at the manifold, resulting in a successful aspiration of a two-inch long thrombus on the first attempt (Figure 2). After aspiration, a 70-80% stenosis in the SVG was visualized that was successfully reduced to 0% using a 3.5 x 18 mm Endeavor drug-eluting stent (Medtronic). TIMI-3 flow was achieved post intervention and the patient tolerated the procedure well, without any in-lab complications (Figure 3). 

Discussion

The GuideLiner catheter is a new device in the coronary interventional field that was originally designed to facilitate guide backup support through deep intubation in complex percutaneous coronary intervention (PCI).² This specific property was utilized in this case to selectively engage the saphenous vein graft and situate the GuideLiner catheter directly above the thrombus. Our case demonstrates a novel approach and illustrates the efficacy of the GuideLiner in performing aspiration thrombectomy after failed attempts to use an aspiration catheter. In our case, the larger lumen of the Guideliner catheter most likely allowed for a better and a complete aspiration of the thrombus. The use of other modalities, such as the AngioJet (Medrad), was contemplated; however, it was felt that the use of thrombolytics and the time needed for the equipment setup would have prolonged the case and might have added to an increased risk of complications. Routinely, a filter wire would be used during PCI of an SVG. However, this SVG was a jump graft and the distal native coronary artery was a small-caliber vessel, which would preclude the use of a filter wire. While this technique proved successful in this particular case, caution must be used when using the GuideLiner catheter for off-label uses. One must meticulously monitor pressure waveforms at all times and ensure there is no hemodynamic compromise. Further prospective study is warranted to investigate the efficacy and safety of this technique for aspiration thrombectomy.

Conclusion

The GuideLiner catheter is a guiding catheter extension that serves to facilitate stent delivery and is approved for providing extra support and coaxial guide engagement. While this device was primarily designed to aid in balloon and stent delivery, we describe a novel use of this catheter to aid in aspiration thrombectomy, which to our knowledge, has never been performed before.

Disclosure: The authors report no financial relationships or conflict of interest regarding the content herein.

This article received a double-blind peer review from the Cath Lab Digest editorial board.

The authors may be contacted via Dr. Farhan Ali at f.ali@hcnt.org.

References

1. Pershad A, Sein V, Laufer N. GuideLiner catheter facilitated PCI — a novel device with multiple applications. J Invasive Cardiol. 2011 Nov; 23(11): E254-259.
2. Cola C, Mirand F, Vaquerizo B, Fantuzzi A, Bruguera J. The Guideliner catheter for stent delivery in difficult cases: tips and tricks. J Interv Cardiol. 2011 Oct; 24(5): 450-461.
3. Wiper A, Mamas M, El-Omar, M. Use of GuideLiner catheter in facilitating coronary and graft intervention. Cardiovasc Revasc Med. 2011 Jan-Feb; 12(1): 68.e5-e7.