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CASE REPORTKorean Circ J 2008;38:287-290 Print ISSN 1738-5520 / On-line ISSN 1738-5555Copyright 2008 The Korean Society of Cardiology

Angioplasty for Difficult Complex Lesions

With Using the Venture

TM

Catheter for Wire PlacementTae Kun Lee, MD1, Sang Kwon Lee, MD2, June Hong Kim, MD1, Jae-Hoon Choi, MD1, Jun Kim, MD1,

Han Cheol Lee, MD1, Kook Jin Chun, MD1, Taek Jong Hong, MD1 and Yung Woo Shin, MD11Departments of Internal Medicine and

2Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Busan, Korea

ABSTRACT

We report here on the use of the VentureTM catheter to facilitate successful advancement of a guidewire acrossdifficult, complex lesions after the prior attempts at guide wire passage were unsuccessful with using standard wires.This VentureTM catheter may increase the success rate and reduce the procedural time for such a challenging in -terventional procedure. (Korean Circ J 2008;38:287-290)

KEY WORDS:Angioplasty; Catheter.

Introduction

Significant angulation and subtotal occlusion are

predictive for procedural failure during percutaneous

coronary intervention.1-3) A proximal stenosis of the

circumflex artery, when combined with severe angulationor no visible stump can confer a higher chance of guid-ewire failure despite the use of modern highly steerableguidewires.

The Venture Catheter (St. Jude Medical Inc., Minn-

eapolis, MN, USA) is the only deflectable catheter for

guidewire delivery in this challenging anatomy. This

catheter is a low-profile, 6 Fr-compatible, torqueable,

support catheter with an 8 mm deflectable atraumaticradiopaque distal tip and it provides support for sub-sequent wire passage. We present here two cases that

demonstrate the benefit of this recently available ca-theter with a deflecting tip to help negotiate subtotal

occlusion or severely angled take-offs of the left circum-flex artery from the left main coronary artery.

Case

Case 1A 61-year old female with a history of hypertension

presented with Canadian Cardiovascular Society Class

III angina. Coronary angiography showed 60 percenttubular eccentric luminal narrowing at the left anteriordescending artery(LAD) ostium and subtotal occlusion

at the left circumflex artery (LCx) ostium. Angiogram

showed no visible stump to pass the guidewire across

the lesion (Fig. 1A).Using the right femoral approach, an 8 French Extra

back-up guiding catheter was engaged in the left maincoronary artery. Initial attempts to cross the left circum-

flex artery ostium were made with hydrophilic-coated

0.014" guidewires such as the BMW (Guidant Corp.,

Santa Clara, CA, USA) and the Choice PT2 (Boston

Scientific., Natick, MA, USA). However, these attempts

were unsuccessful due to the lack of back-up support andthe unsuitable angulation. The VentureTM Wire ControlCatheter was then advanced over the guidewire. The

distal tip of the Venture Catheter was directed toward

the LCx ostial lesion and the tip was deflected to point

towards the origin of the occlusion (Fig. 1B). A 0.014"hydrophilic guidewire was advanced through the Ven-ture Catheter tip. This catheter tip provided back-up

support for the guidewire as it was directed around theangle and across the occlusion. The guidewire was then

continually advanced to the distal LCx(Fig. 1C).After removal of the Venture Catheter, the lesion was

pre-dilated with an undersized balloon (2.020 mm),and a Taxus stent (2.528 mm) was then implanted.

A Taxus stent (4.524 mm) was next deployed fromthe left main coronary artery to the proximal LAD by

using the crushing technique. Finally, kissing balloon-ing was attempted (Fig. 1D). Following the stent de-ployment, a good angiographic result was obtained withcomplete recovery of the LCx, and thrombolysis in

Received: December 27, 2007

Revision Received: January 22, 2008Accepted: February 13, 2008Correspondence: June Hong Kim, MD,Department of Internal Medicine, Pu-san National University School of Medicine, Ami-dong, Seo-gu, Busan

602-739, Korea

Tel: 82-51-240-7795, Fax: 82-51-240-7796

E-mail: aangell@hananet.net

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288Venture Catheter in Complex Lesion

myocardial infarction (TIMI) grade 3 flow was observed(Fig. 1E). The post-procedural intravascular ultrasound(IVUS) findings showed an acceptable result [the mi-nimal stent area (MSA) of the main stent was 10.2 mm2,and the MSA of the LCx ostium was 4.7 mm2](Fig. 2).

Case 2

A 59-year

-old man with hypertension and a history

of smoking presented with unstable angina. He was

previously admitted in another hospital and he was then

transferred to our cardiovascular center for percutaneous

coronary intervention because of the presence of a di-fficult complex lesion. Diagnostic coronary angiographyshowed diffuse long eccentric luminal narrowing at the

LAD (Fig. 3A) and a severely angulated proximal LCxwith subtotal occlusion (Fig. 3B). Although there was a

small remaining stump of the proximal circumflex, itwas angulated at its origin. Despite multiple attempts,

A B C

D EFig. 1. Angiographic findings of first case.A: subtotal occlusion without a visible stump at the ostium of the circumflex artery and there istubular eccentric luminal narrowing at the ostium of the left anterior descending artery. B : the tip of the Venture Catheter was deflectedand engaged at the ostium of the circumflex artery. C: a guidewire is advanced into the distal vessel. D: kissing ballooning after crushingat the bifurcation lesion. E: the final angiographic result following balloon dilation and placement of two drug-eluting stents.

Fig. 2. IVUS findings of first case. A: post-procedural IVUS findings of the left main artery (minimal stent area: 10.2 mm2). B: post-

procedural IVUS findings of the circumflex artery ostium (minimal stent area: 4.7 mm2). IVUS: intravascular ultrasound.

A B

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the wire repeatedly prolapsed distal into the LAD. So,

a microcatheter was positioned in the ostium of the

LCx. This was successfully advanced into the proximallesion, but it was unable to cross the second angle ofthe lesion (Fig. 3C). The distal end of the Venture Ca-theter was advanced into the LAD just beyond the

circumflex origin over a BMW wire (Guidant Corp.,Santa Clara, CA, USA) and it was placed into a curved

configuration by clockwise rotation of the screw me-chanism on the proximal control handle and then itwas gently withdrawn until it engaged the origin of the

LCx. The guide wire was then successfully advancedthrough the catheter into the distal LCx(Fig. 3D) and

the Venture Catheter was removed.

After successful wiring, the pre-procedural IVUS find

-ings showed significant stenosis of the left main coro-

nary artery and the LAD ostium (Fig. 4A and B).

Predilation was performed with an undersized balloon

at the proximal LCx, and a Cypher stent (2.524mm) was deployed. A 3.528 mm Cypher stent wasplaced from the left main coronary artery to the pro-ximal LAD and it was crushed into the LCx stent. After

crushing, a Cypher stent (2.7528 mm) was deployedat the mid LAD. This was followed by kissing ballooning

at the bifurcation lesion (Fig. 3E). We obtained good

angiographic (Fig. 3F and G) and IVUS results (Fig.4C)(the MSA of the LCx ostium was 5.1 mm2).

Discussion

We describe here two cases of using a Venture Catheterto enable access to LCx ostial lesions where severe angu-

A B C D

E F GFig. 3. Angiographic findings of second case.A: initial coronary angiography showed the diffusely diseased lumen of the left anteriordescending artery. B: a severely angulated and subocclusive lesion at the ostium of the circumflex artery. C : an unsuccessful attempt topass a guidewire in the ostium of the circumflex artery by using a microcatheter. This was successfully advanced into the proximallesion, but it was unable to cross the second angle of the lesion. D: the Venture Catheter in a curved configuration engaging the circumflexstump and the guidewire was advanced into the distal vessel. E: kissing ballooning after crushing at the bifurcation lesion. F, G: final results.

Fig. 4. IVUS findings of second case.A: pre-procedural IVUS findings of the distal left main artery (the cross sectional area is 8.9 mm2

and there is a 61% plaque burden). B: pre-procedural IVUS findings of the left anterior descending artery ostium (the cross sectionalarea is 5.5 mm

2and there is a 64% plaque burden). C: post-procedural IVUS findings of the circumflex artery ostium (minimal stent

area: 5.1 mm2). IVUS: intravascular ultrasound.

A B C

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lation and total occlusion caused difficult wire support.The Venture Catheter has previously been documented

for use in tortuous vessels, chronic total occlusion and

in cases of complex interventions that are beyond in-

serting the guide wire into coronary bypass grafts.

4)5)

This device has been used to treat those renal artery

aneurysms that have difficult vasculature.6)

We used a Grapple Hook technique in the second

case. This technique means that the catheter was firstadvanced in its straight configuration over a wire to a

location just beyond the target and only at that pointis it actively flexed and withdrawn to engage the target

vessel. Although there is the potential for causing trauma

to the vessel, the relatively large diameter of the proximalLAD vessel permitted axial rotation and withdrawal of

the catheter with a curved configuration. This approach

was used in a previous report without complications.7)Despite the improvement of the operators technique

and equipment for performing percutaneous coronary

intervention, this procedure can still fail in difficult

complex lesions. We demonstrated that this new device

was useful to facilitate wire passage in severely angulatedvessels and non visible stump lesions. So, this deviceoffers an additional option and it may improve the

procedure success of percutaneous revascularization inthose patients who have difficult vasculature.

REFERENCES

1) Ellis SG, Vandormael MG, Cowley MJ, et al. Coronary morpho-logic and clinical determinants of procedural outcome with an-

gioplasty for multivessel coronary disease: implications for patient

selection. Circulation 1990;82:1193-202.

2) Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morpho-

logic determinants of coronary angioplasty success and compli-

cations: current experience. J Am Coll Cardiol 1995;25:855-65.

3) Yum JH, Jeong MH, Seoung KB, et al. Percutaneous coronary

intervention using crosswireNT

in total occlusion of coronary

artery. Korean Circ J 2002;32:125-30.

4) Naidu SS, Wong SC. Novel intracoronary steerable support ca-

theter for complex coronary intervention. J Invasive Cardiol 2006;

18:80-1.

5) McClure SJ, Wahr DW, Webb JG. Venture wire control catheter.

Catheter Cardiovasc Interv 2005;66

:346-50.6) Aranzulla TC, Colombo A, Sangiorgi GM. Successful endovascular

renal artery aneurysm exclusion using the VentureTM

Catheter

and covered stent implantation: a case report and review of the

literature. J Invasive Cardiol 2007;19:E246-53.

7) McNulty E, Cohen J, Chou T, Shunk K. A grapple hook

technique using deflectable tip catheter to facilitate complex proxi-

mal circumflex interventions. Catheter Cardiovasc Interv 2006;

67:46-8.