Novel Use of Dual Guiding Catheters Technique to Prevent Distal Embolization and Slow Flow during PCI of Coronary Stent Thrombosis

Despite having an incidence of 0.5 to 2%, stent thrombosis has an in-hospital mortality of 15% and myocardial infarction (MI) incidence of 67%. Even with the usage of thrombus aspiration devices and microvasculature vasodilators such as nitroprusside, verapamil, adenosine, and Gp2b/3a inhibitors, the angiographic result of percutaneous coronary intervention of coronary stent thrombosis remains frequently suboptimal due to distal embolization and subsequent slow flow. We describe a novel use of dual guide catheter technique, where one guide acts as conduit for thrombus aspiration catheter and the other for distal placement of balloon trap to prevent distal embolization while managing a case of coronary stent thrombosis to improve the angiographic outcome in this scenario.

Initial Clinical Experience of Repeat Thrombectomy with a Retrieval Stent (RTRS) with Continuous Proximal Flow Arrest by Balloon Guide Catheter for Acute Intracranial Carotid Occlusion

Background. Balloon guide catheters (BGCs) have good performance in terms of radiological outcomes in acute ischemic thrombectomy. It is not uncommon for BGCs to be blocked by thrombi, especially in cases with acute intracranial internal carotid artery (ICA) occlusion. Our initial experience using repeat thrombectomy with a retrieval stent (RTRS) with continuous proximal flow arrest by BGC for acute intracranial ICA occlusion is presented. Methods. In patients with acute intracranial ICA occlusion treated with RTRS, clinical data, including the National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin Scale (mRS) score at 90 days, and procedural data, including the Extended treatment in Cerebral Infarction (eTICI) score, procedural time, and complications, were analyzed. Results. Thirty-two consecutive patients (12 men (37.5%); mean age: 73 years) were treated with RTRS using a BGC. The median NIHSS score was 19. The median puncture-to-reperfusion time was 46 minutes (range: 22-142 minutes). All patients were successfully revascularized; eTICI 2c or better recanalization was achieved in 30 (93.8%) patients. No procedure-related complications or symptomatic intracranial hemorrhage occurred. Two cases (6.3%) had distal emboli, but none had emboli to the anterior cerebral artery. Fourteen patients (43.8%) achieved a good outcome with an mRS score of 0–2 at 90 days, and 8 patients (25.0%) died. Conclusions. In patients with intracranial ICA occlusion, RTRS with proximal flow arrest by BGC is effective and safe, achieving good clinical and angiographic outcomes. This method may reduce the incidence of distal emboli in thrombectomy with stent retrievers.

Successful rotational atherectomy of left main stem with double kiss crush stenting using double guiding catheter: a case report

Background Coronary artery bypass grafting (CABG) is the preferred revascularization procedure for patients with multivessel disease, and those with complex left main disease, as it is associated with a survival advantage in this group of patients. Sometimes however surgical management is not the treatment of choice due to many factors including; ongoing chest pain, hemodynamic instability or patient preference. In these situations, PCI offers an alternative revascularization strategy. In this case study, we present a successful PCI with rotational atherectomy (RA) for distal LMS, LAD and CX using a double guide catheter technique in a patient with severe calcific disease. Case Summery A 63-year-old female was diagnosed with a non-ST elevation myocardial infarction (NSTEMI). Coronary angiography showed significant distal left main stem disease with a severe proximal/ostial calcified lesion of the LAD and a possible thrombotic lesion at the ostium of the CX. She had ongoing hemodynamic instability with chest pain however could not be offered immediate surgical revascularization. We therefore elected to proceed to complex bifurcation LMS coronary intervention using RA under IVUS guidance achieving an excellent final result with TIMI III flow. Discussion This case demonstrates that rotational atherectomy (RA) using the double catheter technique (also known as Ping-Pong) can be safely performed with minimal complication rates and with very favorable angiographic and IVUS results. The clinical outcome was excellent with early discharge.

38 Transcatheter tricuspid valve edge-to-edge repair in patient with severe tricuspid regurgitation and previous mitraclip treatment: when four orifices are better than two

An 82 years old woman was admitted to our Division for worsening dyspnoea. Her past medical history showed: arterial hypertension, chronic atrial fibrillation on oral anticoagulation, a non-critical single-vessel coronary artery disease, previous mitral transcatheter edge-to-edge repair through 2 Mitraclip NTR. After an initial improvement in clinical symptoms following Mitraclip implantation, the patient was admitted several times for acute decompensated heart failure. Haematological exams at admission were normal, exception of NTproBNP (1909 pg/mL). The ECG documented atrial fibrillation with normal ventricular rate. Transthoracic echocardiography demonstrated mid-range heart failure (EF 45–50%) with D-shape morphology of the left ventricle. Colour-doppler analysis shows presence of Mitraclip devices in place with mild residual insufficiency, dilation of the right side, torrential tricuspid regurgitation (tTR) with estimated pulmonary arterial pressure of 45 mmHg. Preprocedural transesophageal echocardiography confirmed these findings showing dilation of the tricuspid annulus with two large regurgitating jets. After positioning Amplatzer Superstiff guide in superior vena cava through guide catheter TSGC0202, a Triclip XT was placed in commissural region between anterior and septal leaflets. A two-grade reduction in tricuspid regurgitation (TR) grade from torrential (5+) to moderate (3+) was achieved without significant transvalvular gradient. The patient was successful discharged after 2 days, asymptomatic and in good clinical conditions. A great reduction in NTproBNP values at discharge was observed (1612 pg/mL). We report a case of successful tricuspid transcatheter repair in patient with chronic decompensated heart failure and previous Mitraclip treatment. The clinical impact of TR reduction is probably due to a positive right ventricular (RV) remodelling, with a reduction in RV size. RV dysfunction and its implications (liver, renal, and haemostatic consequences) are definitely a matter of concern for fragile patients with TR. In fact, many patients with severe TR have a reduced RV function. The reduction in volume and pressure overload of the right heart side, the progressive anatomic and functional reverse of the RV disfunction, may lead to a significant clinical benefit and to a lower hospitalizations rates also through to an important improvement of the left ventricular function as a consequence of the reduction in pressure overload.

452 Saline-induced coronary hyperaemia is mediated by intravascular haemolysis

Aims Absolute coronary blood flow can be measured by intracoronary continuous thermodilution of saline through the lateral side holes of a dedicated infusion catheter placed in the proximal segment of the coronary artery. A room-temperature saline infusion rate at 15–20 ml/min induces an immediate, steady-state, maximal microvascular vasodilation. The mechanism of this hyperemic response remains unclear. The aim of the present study is to test whether local haemolysis is a potential mechanism of coronary hyperaemia. Methods and results Twelve patients undergoing left and right catheterization were included. The left coronary artery and the coronary sinus were selectively cannulated. Absolute resting and hyperemic coronary flow were measured using the continuous intracoronary thermodilution of saline through a dedicated infusion catheter (RayFlow®). Arterial and venous samples were collected from the coronary artery and the coronary sinus in five phases: baseline (BL); resting flow measurement (Rest, saline infusion at 10 ml/min); hyperaemia (Hyperaemia, saline infusion at 20 ml/min); post-hyperaemia [Post-Hyperaemia, 2 min after the cessation of saline infusion; and control phase (Control, during infusion of saline through the guide catheter at 30 mL/min). Haemolysis was visually detected only in the centrifugated venous blood samples collected during the Hyperaemia phase. As compared to Rest, during Hyperaemia both LDH [131.50 ± 21.89 U/dL (Rest) and 258.33 ± 57.40 U/dl (Hyperaemia), P < 0.001] and plasma-free haemoglobin [PFHb, 4.92 ± 3.82 mg/dl (Rest) and 108.42 ± 46.58 mg/dl (Hyperaemia), P < 0.001] significantly increased in the coronary sinus. The percentage of haemolysis was significantly higher during the hyperaemia phase [0.04 ± 0.02% (Rest) vs. 0.89 ± 0.34% (Hyperaemia), P < 0.001]. Conclusions Saline-induced hyperaemia through a dedicated intracoronary infusion catheter is associated with haemolysis. Vasodilatory compounds released locally, like ATP, are likely ultimately responsible for localized microvascular vasodilation. The role of other substances released by erythrocytes in inducing hyperaemia cannot be excluded and requires further investigations.

Abstract 1122‐000229: Simultaneous Transarterial‐Transvenous Contrast Injection to Reveal Connection Point for Treatment of Carotid Cavernous Fistula

Introduction : Cavernous sinus (CS) via inferior petrosal sinus (IPS) access can present a challenge in the treatment of carotid‐cavernous fistulas (CCF) due to anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection. Methods : A 58‐year‐old male was referred to our academic medical center for three weeks of right eye pain, now complicated by redness, diplopia and blurry vision. Magnetic Resonance Imaging (MRI) brain at the outside hospital revealed hemorrhagic lesion in right parietotemporal region. Computerized tomography‐angiogram (CTA) of the head revealed filling of cavernous sinus during an arterial phase suspicious for CCF. Under general anesthesia, after accessing right common femoral artery, 4 French (F) cook catheter (Cook Medical LLC, Bloomington, IN) was advanced over 0.035 angled glide wire to the proximal right internal carotid artery. Contrast injected through the ICA showed the CS but not the IPS (Fig. 1A). Through the left common femoral vein, access was obtained using an Infinity guide catheter (Stryker Neurovascular, Fremont, CA) and Catalyst 5 (Stryker Neurovascular, Fremont, CA) distal access catheter. A Synchro 2 soft microwire (Stryker Neurovascular, Fremont, CA) was advanced through Echelon 10 (Medtronic, Minneapolis, MN) microcatheter. The venous guide catheter was advanced into right internal jugular vein (IJV) and the distal access catheter was placed into sigmoid jugular junction. Injection of contrast revealed the IPS, but not the CS (Fig. 1B). A subsequent simultaneous hand injection with the microcatheter within the IPS and the diagnostic catheter in the left ICA elucidated the venous‐venous connection (Fig. 1C,) allowing for subsequent navigation and complete treatment of the fistula through IPS using target coils (Fig. 1D). Results : Given the arterial system is a high‐pressure system and the usual direction of flow of contrast would be from the high‐pressure ICA to the low‐pressure CS, injecting a simultaneous contrast bolus from the venous end would oppose the arterial contrast flow. As a result, the fistulous connection that was previously obscured became visible allowing roadmap imaging guiding navigation into the CS. Conclusions : Use of simultaneous trans‐arterial/trans‐venous contrast injection is relatively simple compared to other reported techniques to reveal an obscure connection point. It also shortens the duration of endovascular tools in the bloodstream and thus, reduces the potential complication rate. Further use of this technique on larger study samples is important to validate its general use.

Abstract 1122‐000245: Carotid Artery Revascularization Using Walrus Balloon Guide Catheter: Safety and Feasibility from US Multicenter Experience

Introduction : The Walrus Balloon Guide Catheter (BGC) is a new generation of BGC, designed to eliminate conventional BGC limitations during mechanical thrombectomy (MT). We report a multi‐institutional experience using this BGC for proximal flow‐control (PFC) in the setting of carotid artery angioplasty/stenting (CAS) in elective (eCAS) and tandem strokes (tCAS). Methods : Prospectively maintained databases at 7 North‐American Centers were queried to identify patients with cervical carotid disease undergoing eCAS/tCAS with Walrus BGC. Results : 110 patients (median age 68, 64.6% males) undergoing 80 eCAS (72.7%) and 30 tCAS (27.3%) procedures were included (median cervical carotid stenosis 90%; 41.8% with contralateral stenosis). Utilizing proximal flow‐arrest technique in 87.2% and flow‐reversal in 12.8% of procedures, the Walrus was navigated into the common carotid artery (CCA) successfully in all cases despite challenging arch anatomy (28.2%), with preferred femoral access (93.6%) and in conscious sedation (81.8%). Angioplasty and distal embolic protection devices (EPD) were used in 83.7% and 52.7% of procedures, respectively. tCAS led to a mTICI 2b/3 in all cases. Periprocedural ischemic stroke (till 30‐days post‐operatively) rate was 0.9% and remote complications occurred in 1.8% of the cases. Last follow‐up mRS of 0–2 was seen in 95.3% of eCAS cohort, with no differences in complications in the eCAS subgroup between PFC only versus PFC and distal EPD (median follow‐up 4.1 months). Conclusions : Walrus BGC for proximal flow‐control is safe and effective during eCAS and tCAS. Procedural success was achieved in all cases, with favorable safety and functional outcomes on short term follow‐up.