Frequency, Indications, and Outcomes of Guide Catheter Extension Use in Percutaneous Coronary Intervention

Abstract: Background. The frequency and outcomes of guide catheter extension use during percutaneous coronary intervention (PCI) have received limited study. Methods. We retrospectively examined 1539 consecutive PCIs performed between May 2010 and November 2013 to determine the frequency and outcomes of guide catheter extension utilization. Results. During the study period, a guide catheter extension was used in 83 cases (5.4%; 95% confidence interval, 4.3%-6.6%) in 86 vessels. The PCI target vessel was the left anterior descending artery (11%), circumflex (23%), right coronary artery (50%), left main (1%), or a saphenous vein bypass graft (15%). The indications for use (non-mutually exclusive) were to facilitate equipment delivery or provide vessel support/engagement (84.7%), thrombus aspiration (10.5%), retrieval of lost devices (2.3%), facilitation of reverse controlled antegrade and retrograde tracking and dissection (1%), and selective vessel visualization with contrast (1%). Guide catheter extension success rate was 73.3% and technical and procedural success rates were 91.6% and 90.4%, respectively. Four patients (4.8%) experienced a guide catheter extension-related complication: vessel dissection/injury in 2 cases (1 case required emergency coronary artery bypass graft surgery and 1 case required stenting) and equipment loss in 2 cases (1 detachment of the distal guide-extension marker and 1 shearing of a guidewire tip that embolized to the renal artery). Conclusions. In a contemporary patient population undergoing PCI, a guide catheter extension was used in approximately 1 of 20 PCIs. Guide catheter extensions can facilitate procedural success, but also carry low risk for device-related complications.

J INVASIVE CARDIOL 2015;27(10):E211-E215

Key words: percutaneous coronary intervention, balloon angioplasty, complications, guide catheter extension, techniques

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One of the most common challenges of percutaneous coronary intervention (PCI) is inability to deliver equipment to the target coronary lesion. Several techniques can be used to facilitate equipment delivery, mostly by increasing guide catheter support or by modifying the lesion.^1,2 One of the most powerful methods for increasing guide catheter support is use of guide catheter extensions.³

Guide catheter extensions were first introduced in clinical practice in the United States in 2009, and are currently considered “must have” equipment for cardiac catheterization laboratories.^4,5 Not only do they increase guide catheter support, but they have also been used for thrombectomy,⁶ retrieval of dislodged equipment, and selective vessel engagement and opacification. However, their use has also been associated with complications, such as vessel dissection and equipment damage/deformation.^7,8

There is limited systematically collected information on the frequency, indications, and outcomes of guide catheter extension use during PCI. In the present study, we sought to examine the frequency and context of guide catheter extension use and related procedural outcomes in a contemporary PCI series from a tertiary care center with extensive experience in complex coronary interventions.

Methods

Patient population. We reviewed the procedural and clinical records and coronary angiograms of 1539 consecutive patients who underwent PCI between May 2010 and November 2013 at our institution to determine the prevalence, indications, procedural techniques, and outcomes of guide catheter extension use. The study was approved by our institutional review board.

Definitions. Technical success of PCI was defined as achievement of <30% residual diameter stenosis within the treated segment and restoration of Thrombolysis in Myocardial Infarction (TIMI) grade-3 antegrade flow. Procedural success was defined as achievement of technical success with no in-hospital major adverse cardiac event (MACE). In-hospital MACE included any of the following adverse events prior to hospital discharge: death from any cause, Q-wave myocardial infarction, recurrent angina requiring urgent repeat target vessel revascularization with PCI or coronary artery bypass graft surgery, tamponade requiring pericardiocentesis or surgery, and stroke.⁹

Statistical analysis. Clinical characteristics, angiographic measures, and in-hospital outcomes were reported using descriptive statistics. Continuous variables were presented as mean and standard deviation and compared using the t-test or the Wilcoxon rank-sum test, as appropriate. Categorical variables were expressed as percentages and compared using the chi-square or Fisher’s exact test, as appropriate. All statistical analyses were performed with JMP version 11.0 (SAS Institute). Two-sided P-values <.05 were considered to be statistically significant.

Results

Patient characteristics. During the study period, a guide catheter extension was used in 83 of 1539 PCI cases (5.4%; 95% confidence interval, 4.3%-6.6%) in 86 vessels (used in 2 different vessels in 3 cases). The clinical and angiographic characteristics of the study patients are presented in Table 1. Mean age was 69 ± 13 years and all patients were men with high prevalence of diabetes mellitus and hypertension. Most patients presented with an acute coronary syndrome and femoral access was used in most cases (95%). 

Indication for guide catheter extension use. The primary indications for guide catheter extensions were to facilitate equipment delivery or provide vessel support/engagement (84.7%), thrombus aspiration (10.5%), retrieval of lost devices (2.3%), facilitation of reverse controlled antegrade and retrograde tracking and dissection (1%), and selective vessel visualization with contrast (1%).  

Femoral access was used in the majority of cases and guide catheters of all sizes (6, 7, and 8 Fr) were used. The most common target vessel was the right coronary artery and 14.5% of the cases were chronic total occlusion (CTO) interventions. Use of the guide catheter extension was successful in 63 of 86 vessels (73.3%). Technical success was achieved in 76 of 83 patients (91.6%) and procedural success in 75 of 83 patients (90.4%; 1 patient developed stent thrombosis during the index hospitalization).  

Four patients (4.8%) experienced a guide catheter extension-related complication: vessel dissection/injury in 2 cases and equipment loss in 2 cases. One patient had dissection of the proximal circumflex artery, leading to acute vessel closure that eventually required emergency coronary artery bypass graft surgery (Figure 1). Another patient had dissection of the target vessel during equipment delivery attempts that was successfully treated with stenting. In 1 patient, the guide catheter extension distal marker became dislodged into the vessel and was covered with a stent. In another patient, insertion of the guide catheter extension resulted in shearing of a guidewire tip that embolized into the left renal artery, requiring retrieval with a 4-8 mm loop snare (Figure 2).

Discussion

In a contemporary PCI series, we found that guide catheter extensions: (1) are used in approximately 1 of 20 cases; and (2) are associated with high success rates; but (3) also carry low risk for complications. 

Currently, two guide catheter extensions are available for clinical use in the United States: the GuideLiner V3 (Vascular Solutions) and the Guidezilla (Boston Scientific). The GuideLiner was initially approved by the United States Food and Drug Administration in November 2009, and the Guidezilla in March 2013. They are both rapid-exchange, “mother and child” guide catheter extensions. The GuideLiner V3 is manufactured in four sizes (5.5, 6, 7, and 8 Fr), whereas the Guidezilla is only available in 6 Fr.

Frequency of guide catheter extension use. To the best of our knowledge, this is the first study to systematically assess the frequency of guide catheter extension use. A guide catheter extension was used in approximately 1 of 20 PCIs in our study. Use of guide catheter extensions (as with any other type of equipment) depends on several factors, such as case complexity, availability, cost, familiarity with use of the device, and understanding of its potential uses. With increasing use of the device and increased understanding and familiarity, its use has been increasing, especially in laboratories performing complex PCIs.

Indications for guide catheter extension use. Our study confirms that the most common indication for using a guide catheter extension is to facilitate equipment delivery. Although most of our cases were performed using femoral access, facilitating equipment delivery is of particular importance when radial access is used, as it may provide less support than femoral access and limits use of large-bore guide catheters (unless sheathless guide catheters are used). The deeper the intubation length, the greater the support. Deep intubation may be challenging, especially through diseased and calcified vessels, but can be facilitated using a balloon for distal anchoring or for tracking (balloon-assisted tracking). Our findings are in agreement with those of De Man et al, who reported on 70 cases in which a guide catheter extension was mainly used to facilitate stent delivery (59%), to improve alignment of the guide catheter (29%), and for selective contrast injections (13%).

Thrombectomy is another important application of guide catheter extensions. Stys et al reported use of guide catheter extensions for thrombectomy after a dedicated aspiration catheter failed.⁶ Due to their large lumen size, guide catheter extensions may allow removal of large thrombi. When thrombectomy is performed through a guide catheter extension, the guide should be aspirated carefully afterward to prevent inadvertent re-injection of thrombotic material into the target vessel.  

Facilitating CTO interventions is another niche application of guide catheter extensions. Kovacic reported use of the GuideLiner catheter in 28 “balloon-uncrossable” CTOs. The GuideLiner catheter was successful in delivering a small balloon to the CTO lesion in 85.7% of cases, with an overall procedural success rate of 89.3%.¹⁰ Moreover, use of a guide catheter extension can facilitate entry of the retrograde guidewire into the antegrade catheter when employing the reverse controlled antegrade and retrograde tracking and dissection technique.^11,12

Finally, guide catheter extensions allow selective contrast injection, which can improve vessel visualization and also minimize overlap with other vessels that can complicate image interpretation.¹³

Outcomes. Among the 83 cases and 86 target vessels in which a guide catheter extension was used, guide catheter extension success was achieved in 73.3% and technical success in 91.6%, highlighting the clinical utility of the device. 

Previous studies have reported similarly encouraging results. De Man et al reported use of a “5-in-6” Fr guide catheter extension in 70 lesions in 65 consecutive patients undergoing PCI.¹² Overall success rate was 93%. Cola et al reported a series of 10 cases with a success rate of 90%.¹⁴ When guide catheter extensions fail to achieve the desired outcome, additional treatment strategies may be needed, such as additional lesion modification (with balloon angioplasty, laser, or rotational atherectomy) or other strategies to increase guide catheter support, such as side-branch and distal anchoring.

Although use of guide catheter extensions can facilitate procedural success, it can also be associated with complications. Deep vessel engagement can result in vessel injury, as observed in 2 patients in our study. This complication can be prevented by avoiding contrast injection if there is significant pressure dampening. Occasionally, the manifold may be best disconnected to prevent inadvertent contrast injection that could result in distal dissection. If dissection occurs, it is critical to maintain distal guidewire position for stent placement, the definitive treatment for such complications.

De Man et al reported 2 minor complications: air embolism due to insufficient back-bleeding of the guide catheter during insertion of the guide catheter extension, and dislodgment of an undeployed stent when the guide catheter extension was advanced over the guide catheter. Another stent was deployed over the dislodged stent, but postdilation with a balloon led to a good angiographic result.¹³ Cola et al reported a complication in 5 of 10 patients: 3 patients had proximal dissections that were treated with stent implantation, and stents were damaged in 2 cases after passing through the guide catheter extension.¹⁴ Advancing equipment during guide catheter extension use can be challenging, as its lumen is approximately 1 Fr smaller than the lumen in the guide catheter. Damage to stents and guidewires could be prevented by avoiding “forcing” equipment through the guide catheter extension; if resistance is felt, fluoroscopy of the guide catheter extension inlet can clarify the reason for the resistance and help prevent further equipment damage. Bhat et al recently reported a unique complication with dislodgment of the distal cylinder of the GuideLiner from the push rod into the aortic root, which was successfully retrieved.¹⁵

Study limitations. Our study has some important limitations. First, it was a retrospective study from a single tertiary referral center that frequently performs complex PCI, such as saphenous vein graft and chronic total occlusion PCI. Second, as is typical in veteran studies, all patients studied were men, limiting extrapolation of the findings to women. Third, only immediate post-PCI outcomes were collected and included in the study. 

Conclusion

In summary, guide catheter extensions are used in approximately 1 of 20 PCIs and can facilitate procedural success, but also carry low risk for device-related complications.

References

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From the VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. BV Rangan reports grants from InfraredX and Spectranetics. Dr Banerjee reports research grants from Gilead and the Medicines Company; consultant/speaker honoraria from Covidien and Medtronic; ownership in MDCare Global (spouse); intellectual property in HygeiaTel.Dr Brilakis reports consulting/speaker honoraria from St. Jude Medical, Terumo, Asahi Intecc, Somahlution, Abbott Vascular, Elsevier, and Boston Scientific; research support from Boston Scientific and InfraRedx; spouse is employee of Medtronic. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted November 25, 2014, final version accepted November 26, 2014.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, Division of Cardiology (111A), 4500 S. Lancaster Rd, Dallas, TX 75216. Email: esbrilakis@gmail.com