A Unique Complication With Use of the GuideLiner Catheter in Percutaneous Coronary Interventions and its Successful Management

ABSTRACT: The “GuideLiner” is an easy-to-use catheter designed for deep seating in coronary arteries. The GuideLiner can be used to provide extra guidance support for equipment delivery during difficult coronary interventions or for coaxial alignment in tortuous vessels. There are a few GuideLiner-related complications reported in the literature, which include stent damage on advancement or on withdrawal, dissection, pressure dampening and ischemia, kinking of the balloon, and displacement of the GuideLiner catheter distal marker. We report another unique and previously unreported GuideLiner-related complication and its successful management. In our case, we experienced dislodgment of the distal cylinder of the GuideLiner from the push rod into the aortic root. The embolized cylinder was removed percutaneously using a novel approach without any complications.

J INVASIVE CARDIOL 2014;26(4):E42-E44

Key words: GuideLiner, complications, PCI

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Case Report. A 69-year-old Caucasian man with a past medical history of hypertension, dyslipidemia, and coronary artery disease, as well as coronary angioplasty with two bare-metal stents in the mid-left anterior descending (LAD) and the first obtuse marginal artery 6 years prior, presented to our hospital with unstable angina and was referred for cardiac catheterization.

Coronary angiography performed through the radial approach demonstrated an 80% diffuse, highly calcified lesion in the mid-LAD (Figure 1) and a decision was made to proceed with percutaneous coronary intervention.

The left main was engaged with a 6 Fr XB LAD 3.5 guide catheter, which provided excellent support. After multiple balloon inflations in the diseased segment, we were unable to deliver the stent due to calcification and tortuosity. Multiple stent delivery techniques, such as buddy wires including placement of an Ironman wire (Abbott Vascular), were unsuccessful. Finally, a 6 Fr GuideLiner catheter (Figure 2) was used to do one more balloon angioplasty in preparation for stent angioplasty. After balloon angioplasty, the balloon could not be retrieved through the GuideLiner catheter, and due to severe dampening, the whole system including the guiding catheter, the GuideLiner, and the balloon were pulled out from the coronary artery. As we were trying to pull out the GuideLiner catheter, we discovered that the flexible guide extension (distal cylinder) of the GuideLiner was detached from the stainless-steel push tube and was floating into the ascending aorta. Fortunately, the proximal edge of the cylinder was still inside the guiding catheter (Figure 3). To retrieve the cylinder, a guidewire was threaded through the guiding catheter and the flexible guide part (distal cylinder) of the GuideLiner. A small balloon was then delivered past the distal tip of the GuideLiner catheter and inflated. While maintaining balloon inflation, the flexible guide part (distal cylinder) of the GuideLiner was successfully retrieved into the guiding catheter (Figure 4). The whole system was then pulled out without any complications.

The procedure was then resumed through right femoral artery access with successful stent angioplasty of the mid-LAD lesion with no other complications.

Discussion.  Our case highlights a novel potential complication associated with use of the GuideLiner catheter: dislodgment of the distal cylinder of the GuideLiner from its push rod.

The GuideLiner, which is also called the “child” catheter, consists of a 25 cm distal cylinder that is attached to a push rod. A stainless-steel “collar” is located at the transition zone between the cylinder and the push rod. A radiopaque marker is located 2.67 mm from the tip.¹ The GuideLiner is an easy-to-use guide catheter extension that can facilitate vessel engagement and is designed for deep seating in selective coronary arteries, providing extra guide support or coaxial alignment to facilitate easy distal equipment delivery² in both native coronaries and bypass grafts.³ Reported complications of this device include stent damage on advancement or on withdrawal, dissection, pressure dampening and ischemia, and kinking of the balloon.^1,4 There is a previously reported case where the GuideLiner distal marker was displaced into the mid-LAD during the attempts to deliver a stent.¹ A coronary stent was deployed inside the GuideLiner marker, trapping it between the stent and the coronary artery wall, maintaining normal antegrade flow.¹

The failure of balloon retrieval after multiple attempts prompted the operator to pull all hardware out of the coronary artery; displacement between the flexible (distal cylinder) and stainless-steel push tube of the GuideLiner was noticed only afterward. Murphy et al⁵ reported that retraction of the metal transition zone collar of the GuideLiner catheter caused deformation and tearing of a stent balloon. Papayannis et al¹ reported stent loss and deformation occurring during attempts to advance it through the GuideLiner catheter collar. In our case, we believe that the balloon may have gotten stuck at the metal transition zone collar of the GuideLiner catheter, and multiple attempts at removal may have led to fracture and dislodgment of the GuideLiner parts as described. To prevent this complication, Murphy et al⁵ suggested lengthening the silicon-coated straight guide extension beyond its existing 20 cm to 30 cm, which would result in the interface between the stent balloon and GuideLiner collar to be further from the distal aspect of the guide, and more likely to be coaxial within the guiding catheter. This simple modification could prevent deformation and/or damage to the balloon stent during retraction of the GuideLiner.⁵

The distal cylinder measures 25 cm in the new-generation GuideLiner V2; whether this small change will be enough to avoid the above-mentioned complications remains unanswered.⁴

In addition to the GuideLiner, the Guidezilla (Boston Scientific) and Heartrail (Terumo) guide catheter extensions are also available. The Heartrail catheter (not available in the United States) is an over-the-wire system, and thus would not be subject to a complication similar to the one described in this paper.

Conclusion. The use of the GuideLiner for extra support during intervention on complex coronary lesions is not completely safe; in addition to previously reported complications, dislodgment of the GuideLiner distal cylinder is also a rare possibility. It would be prudent for interventionalists to focus on the basics of proper guide and guidewire selection before utilizing guide catheter extensions to facilitate equipment delivery.

References

1. Papayannis AC, Michael TT, Brilakis ES. Challenges associated with use of the GuideLiner catheter in percutaneous coronary interventions. J Invasive Cardiol. 2012;24(7):370-371.
2. Kumar S, Gorog DA, Secco GG, Di Mario C, Kukreja N. The GuideLiner “child” catheter for percutaneous coronary intervention — early clinical experience. J Invasive Cardiol. 2010;22(10):495-498.
3. Chang YC, Fang HY, Chen TH, Wu CJ. Left main coronary artery bidirectional dissection caused by ejection of GuideLiner catheter from the guiding catheter. Catheter Cardiovasc Interv. 2013;82(3):E215-E220 (Epub 2013 Mar 25).
4. Seto A, Kern M. The GuideLiner: keeping your procedure on track or derailing it? Catheter Cardiovasc Interv. 2012;80(3):451-452.
5. Murphy JC, Spence MS. GuideLiner catheter — friend or foe? Catheter Cardiovasc Interv. 2012;80(3):447-450 (Epub 2011 Dec 12). 

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From the ¹Department of Cardiology and ²Department of Medicine, Staten island University Hospital Staten Island, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted July 2, 2013, provisional acceptance given August 19, 2013, final version accepted November 4, 2013.

Address for correspondence: Tariq Bhat, MD, 475 Seaview Ave, Staten Island, NY 10305. Email: mohiuddin_bhat@yahoo.com