Methodology - Clinical Practice (2021) Volume 18, Issue 8
Method of coronary guide-catheter fixation for PCI in patients with previous transcatheter aortic valve implantation
- Corresponding Author:
- Marat Aripov
Department of Interventional Cardiology
National Research Center for Cardiac Surgery
Republic of Kazakhstan
Purpose: Percutaneous coronary interventions after transcatheter aortic valve implantation have been found to be associated with difficulty in guiding catheter cannulation.
Methods and findings: Fixation of the guide catheter to the aortic valve frame using a coronary guidewire and snare was demonstrated to be a simple and reliable method of increasing guide catheter stability.
coronary stenting, guide catheter, aortic stenosis, the engage of guide catheter
ICD: Implantable Cardioverter-Defibrillator, LAD: Anterior Descending, PCI: Percutaneous Coronary Interventions, TAVI: Transcatheter Aortic Valve Implantation
A 78-year-old male moderately overweight patient presented with chief complaints of chest pain, shortness of breath for the past 2 months.
Prior treatments include: Transcatheter Aortic Valve Implantation (TAVI) 3 years prior and ICD implanted 1 year prior due to the cardiac arrest. Normal function of the left ventricle and normal gradient of the aortic valve were revealed by echocardiography. However, coronary angiography showed the ostial stenosis of LAD (VIDEO 1).
VIDEO 1. Compliance to AHA Guidelines.
Methods and results
After insertion of the introducer, the guide catheter was advanced to the ostium of the coronary artery through the closest aortic valve frame cell. Then a coronary wire was inserted through the guiding catheter and the aforementioned cell (VIDEO 2). It was then moved through another cell in the valve frame into the lumen of the ascending aorta. The distal end of this coronary wire was trapped by the snare, which had been delivered from a second arterial access, at the level of the arch or ascending aorta (VIDEO 3). The distal part of the coronary wire was gripped firmly throughout the Percutaneous Coronary Interventions (PCI) process. The snare was then fixed (VIDEO 4). This approach helps achieve reliable and stable fixation of the guide catheter.
https://drfive.google.com/ffile/d/ 12kWFv6RY7oQfi3sShI3-XOaR9BjB5VamU/ vfiew?usp=sharfing
VIDEO 2. AP Projection of the LCA. Projection with the advancing wire through the guiding catheter and the frame cell into the lumen of the ascending aorta.
VIDEO 3. AP Projection. The distal end of this coronary wire was trapped by the snare.
https://drive.google.com/file/d/13V4Vco_ Rqp-R7Gs8JuUQG0OpYxZswXPl/ view?usp=sharing
VIDEO 4. Writing of LAD and Cx. Two coronary guidewires were inserted sequentially in the distal parts of the LAD and intermedia. Predilation with a 2.0-20.0 mm balloon of the distal left main and proximal parts of LAD was performed.
Provisional stenting of the left main and the proximal part of the Left Anterior Descending (LAD) artery was performed without any challenges. Initial coronary angiography revealed severe calcinosis of the bifurcation of the left main, LAD, and the 90º angle between them, which could present difficulties for balloon and stent insertion. Two coronary guidewires were inserted sequentially in the distal parts of the LAD and intermedia (VIDEO 5). Predilation with a 2.0 mm-20.0 mm balloon at 12 atm of the distal left main and proximal parts of LAD was performed, but success was minimal (VIDEO 6). For this reason, predilation with a 2.25-15.0 non-compliant balloon at 17 atm was performed and a Resolute Onyx stent 3.0 mm- 22.0 mm was implanted in the left main and proximal part of LAD (VIDEO 7). Proximal optimization therapy with a 3.5-12.0 noncompliant balloon was performed as the next stage (VIDEO 8). The final result is shown in the VIDEO 9.
https://drive.google.com/file/d/1TZgpMSw-e_ GKPMwYdcFg5NBAa5Bnu5pU/ view?usp=sharing
VIDEO 5. The coronary angiography after predilatation. A severe calcinosis of the bifurcation of the left main, LAD, and the 90º angle between them.
https://drive.google.com/file/d/1YmzC CGDjexCXmCIBet1bWY9n72RQMpc8/ view?usp=sharing
VIDEO 6. Predilation. The kissing predilatation LAD and intermedia.
https://drive.google.com/file/d/1Y2F 5tq57pRX1Fl5S9J9MAZsadBAAbhKt/ view?usp=sharing
VIDEO 7. The stenting. The advancing of the stent and placement in the left main and proximal part of LAD.
https://drive.google.com/file/ d/1Eqnsn4U4w9rs_NXXM6c2aO00UDrKC0Qz/ view?usp=sharing
VIDEO 8. AP view. Proximal optimization therapy with a 3.5-12.0 non-compliant balloon was performed.
VIDEO 9. Final result. Final view after placement of the stent.
Echocardiography was performed after the procedure to assess the function of the aortic valve which did not reveal any damage of the flaps (VIDEO 10). The patient noted a significant improvement in his well-being and was discharged three days after the procedure.
https://drive.google.com/file/d/1tldenz SCNuAQYNXotMazzsRWg6kDMOwm/ view?usp=sharing
VIDEO 10. Echo. Apical view of the aortic valve.
Discussion and conclusion
Coronary angiography and PCI will become increasingly required in patients after TAVI . Several reports have shown that there are technical difficulties with coronary engagement, particularly in patients with Evolut [2,3]. This difficulty may be due to the following factors the frame waist is narrower than the aorta and there was more space between the frame and the coronary ostia, TAVI commissural post, bulky old leaflet. Some authors suggest the use of an Extension Catheter Guidion for stenting . The most interesting finding in this case was that the frame can actually help in supporting the guiding catheter. This finding was unexpected and suggests that the fixation of the guiding catheter improve coronary engagement significantly after using this technique. A possible explanation for this benefit might be during PCI treatment of the chronic total occlusion and complex stenosis. This method finding cannot be applied to patients after TAVI with other valve types.
The patient was seen 3 months following stenting. No clinical concerns were noted; the patient exhibited no initial symptoms and reported no complaints. In conclusion, fixation of the guide catheter to the aortic valve frame using a coronary guidewire and snare was demonstrated to be a simple and reliable method of increasing guide catheter stability.
Case; The clinical case described here a method of effective guide catheter fixation after TAVI. To obtain insure reliable support of guiding catheter for PCI after TAVI.
Authors declare that they have no conflict of interest. No relationship with industry.
There is no specific funding.
- Yudi MB, Sharma SK, Tang GH, et al. Coronary angiography and PCI after TAVR. J Am Coll Cardiology. 71, 1360-1378 (2018).
- Diaz МA, Patton M, Valdes P, et al. A systematic review and meta-analysis of delayed coronary artery access for coronary angiography with or without Percutaneous Coronary Intervention (PCI) in patients who underwent Transcatheter Aortic Valve Replacement (TAVR). Cardiovasc Interv Ther. (2021).
- Zivelonghi C, Lunardi M, Pesarini G, et al. Coronary artery disease in patients undergoing transcatheter aortic valve implantation. A single center registry on prevalence, management and immediate clinical impact. Cor et Vasa. 59, е23-e28 (2017).
- Tanaka А, Jabbour RJ, Incidence LT, et al. Incidence, Technical Safety, and Feasibility of Coronary Angiography and Intervention Following Self-expanding Transcatheter Aortic Valve Replacement. Cardiovas Revasc Med. 20, 371-375 (2019).