The GuideLiner-Sleeve Technique: A Novel Technique for High-Risk PCI Using Two Left Main Guides for Orbital Atherectomy of Two-Vessel Calcified Ostial Coronary Artery Disease

J INVASIVE CARDIOL 2017;29(11):E159-E160.

Key words: percutaneous coronary interventions, orbital atherectomy, GuideLiner

An 85-year-old woman with known coronary artery disease (prior stents in the left anterior descending [LAD] and left circumflex [LCX] coronary arteries placed in 1996), presented with chest pain. A 12-lead electrocardiogram (ECG) revealed 1 mm ST-segment elevation in V4-V6. Bedside two-dimensional echocardiogram demonstrated LAD territory wall-motion abnormalities and the patient was taken emergently to the catheterization laboratory.  

Cardiac catheterization revealed multivessel coronary artery disease with severe calcific ostial LAD and LCX disease. An intra-aortic balloon pump was inserted and the symptoms and ECG changes resolved. The patient later became symptomatic in the intensive care unit, with dynamic ECG changes (Figure 1A), but refused surgical revascularization. A high-risk percutaneous coronary intervention was then planned after discussion with the multidisciplinary team. 

A percutaneous left ventricular assist device was inserted for hemodynamic support. We devised a novel “GuideLiner-sleeve” technique to perform orbital atherectomy of the ostial LAD and LCX (Figures 1B-1G), protecting each vessel with a coronary guidewire while performing atherectomy of the other vessel. We used two guiding catheters from bilateral radial arteries to wire both the LAD and LCX. We advanced a GuideLiner catheter (Vascular Solutions) as a sleeve over the guidewire in the LAD and performed orbital atherectomy of the LCX ostial lesion, then reversed the configuration to perform atherectomy of the LAD while protecting the LCX. Following orbital atherectomy, left main bifurcation stenting was successfully completed using the double-kissing crush technique.¹ The patient was subsequently discharged home in stable condition and remains well at follow-up.

Our novel GuideLiner-sleeve technique enabled use of atherectomy in calcific ostial lesions of the LAD and LCX. Due to the differential sanding effect, the GuideLiner effectively protects the second guidewire, allowing safe access to the second major epicardial vessel throughout the procedure. 

Reference

1.    Chen SL, Xu B, Han YL, et al. Clinical outcome after DK crush versus culotte stenting of distal left main bifurcation lesions: the 3-year follow-up results of the DKCRUSH-III study. JACC Cardiovasc Interv. 2015;8:1335-1342.

From the ¹Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois; and the ²Division of Interventional Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kakouros reports consultant fees from Cardiovascular Systems, Inc. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted October 11, 2017.

Address for correspondence: Abdul Moiz Hafiz, MD, Assistant Professor of Medicine, Division of Cardiology, Southern Illinois University School of Medicine, 701 North 1st Street, MMC Suite D417, PO Box 19636, Springfield, IL 62794-9636. Email: hafizabdulmoiz@hotmail.com