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The GuideLiner “Child” Catheter for Percutaneous Coronary Intervention — Early Clinical Experience
ABSTRACT: The failure to deliver a stent across the target lesion during percutaneous coronary intervention, especially in arteries with calcified tortuous anatomy, is often due to insufficient back-up support from the guiding catheter. Deep-vessel intubation with the guiding catheter may overcome this problem, but risks coronary dissection. The Heartrail II (Terumo, Japan) “five–in-six catheter system” (or “mother-and-child” catheter) comprises a flexible-tipped long 5 Fr catheter advanced through a standard 6 Fr guiding catheter to deeply intubate the target vessel, thus providing enough back-up support to enable stent delivery. Here we describe a newly developed “child” support catheter (The GuideLiner; Vascular Solutions, Inc., Minneapolis, Minnesota), report its successful use in a series of 4 difficult cases, and discuss practical tips to optimize its performance.
The failure to deliver a stent across the target lesion during percutaneous coronary intervention (PCI), especially in arteries with calcified tortuous anatomy, is often due to insufficient backup support from the guiding catheter. Commonly used methods to overcome this problem include vessel straightening with a second “buddy” wire1,2 or “buddy” balloon,3 the use of an anchor balloon4 and the use of guiding catheters of larger caliber and more supportive shape. Deep-vessel intubation with the guiding catheter may also help, but risks coronary dissection. The Heartrail II (Terumo, Japan) “five-in-six catheter system” (or “mother-and-child” catheter) comprises a flexible-tipped, long (120 cm) 5 French (Fr) catheter advanced through a standard 6 Fr guiding catheter to deeply intubate the target vessel.5-7 This system uses the target vessel itself to provide the extra backup support required for stent delivery. Furthermore, the absence of a primary curve and the flexibility of its tip permit the “child” catheter to remain coaxial with the target vessel, thereby minimizing the risk of catheter-induced coronary dissection. Here we describe a newly developed “child” support catheter8 (GuideLiner; Vascular Solutions, Inc., Minneapolis, Minn.), report its successful use in a series of 4 difficult cases, and discuss practical tips to optimize its performance.
guiding catheter on a monorail. It is comprised of a flexible yellow 20-cm straight extension (internal diameter approximately one French size smaller than the guiding catheter) connected to a stainless-steel push tube, with a “collar” that can be deployed through the existing Y-adapter for rapid exchange delivery (Figure 1). It neither lengthens the guiding catheter nor requires a second hemostatic valve. The extension comprises an inner polytetrafluoroethylene (PTFE: Teflon) lining, surrounded by a stainless-steel coil (imparts flexibility and strength) and an outer layer of Pebax® polymer. Its silicon coating imparts lubricity.
Passage of the Guideliner through the guiding catheter is designed to be tight in order to 
prevent slippage. Delivery of the extension into the target vessel is aided by a radiopaque marker located 0.105" (2.66 mm) from the tip and white positioning markers on the push tube at 95 cm (single) and 105 cm (double) (Figure 2). The GuideLiner is currently available in three sizes: 5-in-6 Fr (internal diameter 0.056"), 6-in-7 Fr (0.062") and 7-in-8 Fr (0.071").
The GuideLiner catheter permits very deep intubation of the target vessel, thus providing backup support to facilitate stent delivery across heavily calcified lesions in tortuous vessels. The deeply-engaged extension is always aligned coaxial to the target vessel, and this is particularly useful if the takeoff of the coronary ostium prevents coaxial engagement of the guiding catheter. Furthermore, it enables the injection of radiocontrast close to the target lesion, improving its visualization. The manufacturer does not recommend its use in target vessels of Case 1. Percutaneous intervention of a tortuous calcified mid right coronary artery (RCA). A 74-year-old patient who had previously undergone coronary artery bypass grafting 
was admitted with an inferolateral non-ST-elevation myocardial infarction (NSTEMI). His angiogram showed a moderate proximal stenosis of the left anterior descending artery (LAD) and a severe proximal stenosis of the small circumflex. The graft to the LAD was occluded, but there was a patent graft which back-filled the right posterior descending artery up to the crux. The RCA was tortuous and calcified, with severe stenoses of the proximal and mid vessel (Figure 3a), rendering the posterolateral territory a substrate for ischemia.
Angioplasty to the native RCA was performed using a 6 Fr sheath inserted in the right femoral artery. An Amplatz Left (AL) 1 guiding catheter was used after failure to adequately engage the RCA with a hockey stick catheter. A Balance MiddleWeight (BMW) wire (Abbott Vascular, Redwood City, Ca.) was passed to the distal RCA. Despite predilatation of the mid-RCA lesion with both 2.5 x 15 mm and 3.0 x 15 mm Maverick balloons (Boston Scientific Corp., Natick, Mass.) (Figure 3b) and the use of a “buddy” balloon, a stent could not be delivered across the lesion due to a combination of vessel calcification and tortuosity. Therefore, a GuideLiner catheter was inserted into the 6 Fr guiding catheter, and the GuideLiner tip was advanced up to the mid RCA to provide the support required for stent delivery (Figure 3c). This permitted the easy deployment of 4 overlapping drug-eluting stents from the mid vessel to the ostium of the RCA (3.5 x 15 mm, 3.5 x 18 mm, 3.5 x 23 mm and 3.5 x 8 mm Promus stents; Boston Scientific). After serial postdilatation of the entire stented segment with noncompliant balloons, a good final angiographic result was achieved (Figure 3d). The patient was discharged the following day without complications.
Case 2. Percutaneous intervention of severe in-stent restenosis of the RCA. A 55-year old diabetic male had previously undergone coronary bypass surgery, and more recently angioplasty with multiple stents to the large native RCA (proximal and mid-thirds, and its posterolateral branch [PLA]). He re-presented with NSTEMI. Diagnostic angiography 
(Figure 4a) revealed the culprit to be restenosis of the RCA (severe at the mid-vessel and just proximal to the crux, subtending a very large posterolateral branch). Angioplasty to the native RCA was performed using a 6 Fr hockey stick guiding catheter from the right femoral approach. A BMW wire was passed to the PLA. Despite serial predilatations of the mid and distal RCA with a 3.0 x 15 mm noncompliant balloon (Figure 4b), and despite employing a “buddy” wire, a stent could not be delivered across the distal lesion. This was in part due to the rigidity of the extensively stented vessel, and partly because the vessel could not be adequately intubated with the guiding catheter (leading to poor backup support). A 5 Fr GuideLiner catheter was passed down the RCA to the mid-vessel lesion (Figure 4c), enabling full intubation of the proximal RCA with the guiding catheter and permitting stent delivery to the distal restenosis (3.5 x 13 mm Cypher Select; Cordis Corp., Miami Lakes, Fl.). The mid-RCA stenosis was treated with a 3.5 x 23 mm Promus stent. The final angiographic result was very good (Figure 4d).
Case 3. Percutaneous intervention of a chronic total occlusion of the RCA. A 68-year-old male with stable angina underwent diagnostic angiography which revealed occlusion of the mid RCA just distal to its right ventricular branch, and only minor branch disease in the left coronary artery. Angioplasty of the RCA was performed via the right femoral artery using a well-engaged 6 Fr AR 1 guiding catheter. A Whisper MS (Abbott Vascular) wire was passed to the distal RCA, with the intraluminal wire position confirmed by retrograde filling from a contralateral injection of the left coronary artery. A 1.0 x 10 mm over-the-wire balloon was required to cross and predilate the lesion. Serial predilatations with a 2.0 x 12 mm Maverick and a 2.5 x 12 mm Quantum Maverick balloon (Boston Scientific) were performed, but no stent could be passed beyond the tortuous proximal RCA. Therefore, a 5 Fr GuideLiner catheter was passed beyond the proximal RCA, employed to deliver a 3.0 x 28 mm Promus stent across the mid RCA, and postdilated with a 3.5 x 12 mm Quantum Maverick balloon. The final angiographic result was very good.
Case 4. Percutaneous intervention of a chronic total occlusion of the RCA. A 77-year-old female developed recurrent angina 7 years after coronary artery bypass graft 
surgery. Diagnostic angiography revealed patent LAD and circumflex grafts, and occlusion of the RCA vein graft. The native RCA was occluded in its mid course, with significant stenosis proximal to the occlusion (Figure 5a). The distal RCA was seen to backfill from a contralateral injection of the left internal mammary graft via distal LAD collaterals, which, owing to their epicardial location, were considered unsuitable for a retrograde approach to the RCA.
Therefore, antegrade angioplasty of the RCA chronic total occlusion was undertaken via the right femoral artery using a 6 Fr FR4 guiding catheter. First, the proximal RCA was treated with a 2.75 x 16 mm Promus Element stent to facilitate the distal passage of equipment. The occlusion was successfully crossed (confirmed by contralateral injection) with a Pilot 50 wire (Abbott Vascular) and 1.0 mm over-the-wire (OTW) balloon support. However, it was not possible to pass any equipment across the occlusion (1.0 mm OTW balloon, 1.25 mm Maverick balloon, a Corsair catheter and a Tornus catheter all failed to cross), even with additional guide-catheter support from an “anchor” balloon placed in the right ventricular branch. Therefore, a 5 Fr GuideLiner “child” catheter was passed to the mid RCA (Figure 5b), after which a 0.9 mm laser catheter was employed, and this crossed the occlusion with ease. With the GuideLiner catheter in situ, serial predilatations of the occlusion were performed and 4 additional overlapping Promus Element stents were deployed (2.75 x 12, 3.0 x 12, 3.0 x 16 and 3.0 x 16 mm), with a good final angiographic result (Figure 5c).
Device and Technical Detail
The GuideLiner catheter is a coaxial guiding catheter extension delivered through a standard
guiding catheter on a monorail. It is comprised of a flexible yellow 20-cm straight extension (internal diameter approximately one French size smaller than the guiding catheter) connected to a stainless-steel push tube, with a “collar” that can be deployed through the existing Y-adapter for rapid exchange delivery (Figure 1). It neither lengthens the guiding catheter nor requires a second hemostatic valve. The extension comprises an inner polytetrafluoroethylene (PTFE: Teflon) lining, surrounded by a stainless-steel coil (imparts flexibility and strength) and an outer layer of Pebax® polymer. Its silicon coating imparts lubricity.
Passage of the Guideliner through the guiding catheter is designed to be tight in order to 
prevent slippage. Delivery of the extension into the target vessel is aided by a radiopaque marker located 0.105" (2.66 mm) from the tip and white positioning markers on the push tube at 95 cm (single) and 105 cm (double) (Figure 2). The GuideLiner is currently available in three sizes: 5-in-6 Fr (internal diameter 0.056"), 6-in-7 Fr (0.062") and 7-in-8 Fr (0.071").
The GuideLiner catheter permits very deep intubation of the target vessel, thus providing backup support to facilitate stent delivery across heavily calcified lesions in tortuous vessels. The deeply-engaged extension is always aligned coaxial to the target vessel, and this is particularly useful if the takeoff of the coronary ostium prevents coaxial engagement of the guiding catheter. Furthermore, it enables the injection of radiocontrast close to the target lesion, improving its visualization. The manufacturer does not recommend its use in target vessels of Case 1. Percutaneous intervention of a tortuous calcified mid right coronary artery (RCA). A 74-year-old patient who had previously undergone coronary artery bypass grafting 
was admitted with an inferolateral non-ST-elevation myocardial infarction (NSTEMI). His angiogram showed a moderate proximal stenosis of the left anterior descending artery (LAD) and a severe proximal stenosis of the small circumflex. The graft to the LAD was occluded, but there was a patent graft which back-filled the right posterior descending artery up to the crux. The RCA was tortuous and calcified, with severe stenoses of the proximal and mid vessel (Figure 3a), rendering the posterolateral territory a substrate for ischemia.
Angioplasty to the native RCA was performed using a 6 Fr sheath inserted in the right femoral artery. An Amplatz Left (AL) 1 guiding catheter was used after failure to adequately engage the RCA with a hockey stick catheter. A Balance MiddleWeight (BMW) wire (Abbott Vascular, Redwood City, Ca.) was passed to the distal RCA. Despite predilatation of the mid-RCA lesion with both 2.5 x 15 mm and 3.0 x 15 mm Maverick balloons (Boston Scientific Corp., Natick, Mass.) (Figure 3b) and the use of a “buddy” balloon, a stent could not be delivered across the lesion due to a combination of vessel calcification and tortuosity. Therefore, a GuideLiner catheter was inserted into the 6 Fr guiding catheter, and the GuideLiner tip was advanced up to the mid RCA to provide the support required for stent delivery (Figure 3c). This permitted the easy deployment of 4 overlapping drug-eluting stents from the mid vessel to the ostium of the RCA (3.5 x 15 mm, 3.5 x 18 mm, 3.5 x 23 mm and 3.5 x 8 mm Promus stents; Boston Scientific). After serial postdilatation of the entire stented segment with noncompliant balloons, a good final angiographic result was achieved (Figure 3d). The patient was discharged the following day without complications.
Case 2. Percutaneous intervention of severe in-stent restenosis of the RCA. A 55-year old diabetic male had previously undergone coronary bypass surgery, and more recently angioplasty with multiple stents to the large native RCA (proximal and mid-thirds, and its posterolateral branch [PLA]). He re-presented with NSTEMI. Diagnostic angiography 
(Figure 4a) revealed the culprit to be restenosis of the RCA (severe at the mid-vessel and just proximal to the crux, subtending a very large posterolateral branch). Angioplasty to the native RCA was performed using a 6 Fr hockey stick guiding catheter from the right femoral approach. A BMW wire was passed to the PLA. Despite serial predilatations of the mid and distal RCA with a 3.0 x 15 mm noncompliant balloon (Figure 4b), and despite employing a “buddy” wire, a stent could not be delivered across the distal lesion. This was in part due to the rigidity of the extensively stented vessel, and partly because the vessel could not be adequately intubated with the guiding catheter (leading to poor backup support). A 5 Fr GuideLiner catheter was passed down the RCA to the mid-vessel lesion (Figure 4c), enabling full intubation of the proximal RCA with the guiding catheter and permitting stent delivery to the distal restenosis (3.5 x 13 mm Cypher Select; Cordis Corp., Miami Lakes, Fl.). The mid-RCA stenosis was treated with a 3.5 x 23 mm Promus stent. The final angiographic result was very good (Figure 4d).
Case 3. Percutaneous intervention of a chronic total occlusion of the RCA. A 68-year-old male with stable angina underwent diagnostic angiography which revealed occlusion of the mid RCA just distal to its right ventricular branch, and only minor branch disease in the left coronary artery. Angioplasty of the RCA was performed via the right femoral artery using a well-engaged 6 Fr AR 1 guiding catheter. A Whisper MS (Abbott Vascular) wire was passed to the distal RCA, with the intraluminal wire position confirmed by retrograde filling from a contralateral injection of the left coronary artery. A 1.0 x 10 mm over-the-wire balloon was required to cross and predilate the lesion. Serial predilatations with a 2.0 x 12 mm Maverick and a 2.5 x 12 mm Quantum Maverick balloon (Boston Scientific) were performed, but no stent could be passed beyond the tortuous proximal RCA. Therefore, a 5 Fr GuideLiner catheter was passed beyond the proximal RCA, employed to deliver a 3.0 x 28 mm Promus stent across the mid RCA, and postdilated with a 3.5 x 12 mm Quantum Maverick balloon. The final angiographic result was very good.
Case 4. Percutaneous intervention of a chronic total occlusion of the RCA. A 77-year-old female developed recurrent angina 7 years after coronary artery bypass graft 
surgery. Diagnostic angiography revealed patent LAD and circumflex grafts, and occlusion of the RCA vein graft. The native RCA was occluded in its mid course, with significant stenosis proximal to the occlusion (Figure 5a). The distal RCA was seen to backfill from a contralateral injection of the left internal mammary graft via distal LAD collaterals, which, owing to their epicardial location, were considered unsuitable for a retrograde approach to the RCA.
Therefore, antegrade angioplasty of the RCA chronic total occlusion was undertaken via the right femoral artery using a 6 Fr FR4 guiding catheter. First, the proximal RCA was treated with a 2.75 x 16 mm Promus Element stent to facilitate the distal passage of equipment. The occlusion was successfully crossed (confirmed by contralateral injection) with a Pilot 50 wire (Abbott Vascular) and 1.0 mm over-the-wire (OTW) balloon support. However, it was not possible to pass any equipment across the occlusion (1.0 mm OTW balloon, 1.25 mm Maverick balloon, a Corsair catheter and a Tornus catheter all failed to cross), even with additional guide-catheter support from an “anchor” balloon placed in the right ventricular branch. Therefore, a 5 Fr GuideLiner “child” catheter was passed to the mid RCA (Figure 5b), after which a 0.9 mm laser catheter was employed, and this crossed the occlusion with ease. With the GuideLiner catheter in situ, serial predilatations of the occlusion were performed and 4 additional overlapping Promus Element stents were deployed (2.75 x 12, 3.0 x 12, 3.0 x 16 and 3.0 x 16 mm), with a good final angiographic result (Figure 5c).
Discussion
This is, to our knowledge, the first published case series of coronary intervention using the GuideLiner “child” catheter. All cases involved intervention of the RCA, for which extra backup support is often required. In some cases, stent delivery was impossible despite the use of a highly supportive guiding catheter, buddy wires and a buddy balloon. The GuideLiner catheter provided the additional backup support required for stent delivery. Deep target-vessel intubation was possible without displacement of the guiding catheter/wire or vessel trauma. Its safety relates to the flexibility of the guide extension and the absence of a primary curve, thereby minimizing the risk of catheter-induced target vessel dissection. Its coil backbone imparts both flexibility and strength to the catheter. Its use results in the loss of only 1 French size, so that almost all devices will still fit through a 6 Fr GuideLiner (internal diameter 0.056"). For a larger working lumen, the GuideLiner can easily be removed while the wires are left in place. Rapid exchange helps with deployment through the existing hemostatic valve without extending the guiding catheter length, and so does not limit the useable length of balloons and wires.Tips for Optimal Performance
- The GuideLiner should be inserted through the guiding catheter over a 0.014" primary guidewire to a maximum of 10 cm beyond the guiding catheter tip under fluoroscopy. This limit is prescribed to avoid extending the collar over the secondary curve of the guiding catheter.
- Intubation by more than 20 cm will result in the whole extension exiting the guiding catheter.
- When inserting the GuideLiner into the guiding catheter, the flat push-tube should be oriented in a lateral position and should be further advanced without rotation to avoid wrapping of the guidewire.
- Deep-vessel engagement by the GuideLiner can be facilitated by passage of a balloon catheter over the primary wire into the distal vessel, followed by low-pressure balloon inflation. This acts as an anchor to support gentle advancement of the GuideLiner.
- Stents should be advanced through the GuideLiner over the primary guidewire, as secondary wires may wrap around the GuideLiner and obstruct stent insertion.
- In cases of resistance while inserting a guidewire or stent through the GuideLiner, the location of the wire or stent in relation to the metal collar of the GuideLiner should be checked and the stent inspected for signs of damage prior to readvancement. To correct any resistance that occurs at (or proximal to) the collar:
- If a secondary wire is in use, check for wrapping of the secondary wire around the GuideLiner. If wire wrap is evident, consider pulling back the secondary wire and readvancing it. Alternatively, if the primary wire is still in place, consider advancing the stent over the primary wire.
- If a stent continues to encounter resistance at the metal collar, pull the stent and guidewire back together 3–5 cm and try readvancing the stent and guidewire together through the metal collar. If resistance is again encountered, check the stent for signs of damage and either choose a lower-profile stent or change the guidewire.
References
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- Jafary FH. When one won't do it, use two-double “buddy” wiring to facilitate stent advancement across a highly calcified artery. Catheter Cardiovasc Interv 2006;67:721–723.
- Li SS, Cheng CW. Coronary angioplasty on an impassable calcified stenosis using a buddy balloon technique. Catheter Cardiovasc Interv 2004;62:35–37.
- Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during advancement of a balloon in coronary angioplasty: The anchor technique. Catheter Cardiovasc Interv 2003; 59:482–488.
- Takahashi S, Saito S, Tanaka S, et al. New method to increase a backup support of a 6 French guiding coronary catheter. Catheter Cardiovasc Interv 2004;63:452–456.
- Shaukat A, Al-Bustami M, Ong PJ. Chronic total occlusion — Use of a 5 French guiding catheter in a 6 French guiding catheter. J Invasive Cardiol 2008;20:317–318.
- Mamas MA, Eichhofer J, Hendry C, et al. Use of the Heartrail II catheter as a distal stent delivery device; An extended case series. EuroIntervention 2009;5:265–271.
- Rao U, Gorog DA, Szygula J, et al. The GuideLiner “child” catheter. EuroIntervention 2010 Jun;6(2):277–279.
