Coronary angioplasty with 7F guiding catheters

The performance of 7F guiding catheters for percutaneous transluminal coronary angioplasty (PTCA) was investigated in 300 patients. A total of 233 patients had single-vessel PTCA and 67 had multivessel PTCA. Angioplasty was attempted for 371 lesions (141 [38%] in the left anterior descending, 124 [33%] in the right coronary artery, and 95 [26%] in the left circumflex coronary artery or their branches; 10 [3%] in a bypass graft, and one in the left main stem). The mean degree of stenosis was 86 f 11% (range 60% to 100%). The monorail technique was used in 83%, and balloon-on-a-wire devices were used in 6% of cases. The balloon sizes varied between 2.0 and 4.25 mm. There was a 98% technical success rate for the 325 nontotal lesions. Five could not be crossed with the wire. Exchange to an 8F guiding catheter was done in four cases (1.2%) and yielded success in two of them. In 46 occlusions the success rate was 72%. Nine were failures due to an inability to cross the wire, another two were balloon failures, and in two cases the residual stenosis was >50%. The mean residual stenosis of successful cases was 24 k 18%. Overall, the primary success rate was 95%. The complications were: in-hospital death in five patients (1.7%); infarction in 12 (4%); emergency bypass surgery in one; and significant inguinal’hematoma in five (1.7%). Coronary angioplasty through 7F guiding catheters yields a high success rate with less coronary wedging and a smaller puncture hole. (AM HEART J lgg1;122:151g.)

Ramon Villavicencio, MD, Bernhard Meier, MD, Abhay K. Pande, MD, Philip Urban, MD, Juan Sztajzel, MD, and Fernando de la Serna, MD. Geneva, Switzerland

When percutaneous transluminal coronary angio- plasty was introduced,l only rigid guiding catheters of solid Teflon with an outer diameter of 9.4F (3.1 mm) were available. Later, guiding catheters with outer diameters of 9F (3.0 mm) or 8F (2.7 mm) became standard. They are composed of three layers: an outer layer of polyurethane or polyethylene to provide axial support and curve memory; a middle wire braid layer to enhance torque transmission; and an inner lumen lined with Teflon to provide a low co- efficient of friction and allow for smooth balloon pas- sage. One of the main remaining problems is cathe- ter wedging in the coronary orifice, which causes decreased coronary perfusion and increases the risk of both intimal trauma and ischemic dysrhythmias. Soft-tip guiding catheters may prevent intimal trauma, but not wedging,2-4 for which 7F guiding catheters promise help in addition to making a smaller puncture hole with reduced risk of local bleeding. The purpose of this study is to analyze the technical performance and the clinical results of 7F guiding catheters for coronary angioplasty.

From the Cardiology Center, University Hospital, Geneva.

Received for publication Nov. 13, 1990; accepted June 7, 1991.

Reprint requests: Bernhard Meier, MD, Cardiology Center, University Hospital, 1211 Geneva 4, Switzerland.

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METHODS

Between August 1988 and March 1990, coronary angio- plasty of 371 lesions was attempted through 7F guiding catheters (Soft-Touch, Schneider-Europe, Zurich, Switzer- land; outer diameter 2.3 mm and inner diameter 1.6 mm or 0.063 in) using coronary balloon systems. There was one percutaneous axillary procedure, the remainder were fem- oral. A 7F-sheath (outer diameter 2.7 mm) was used in all cases. During the initial manipulations of the guide wire across the lesion, the guide wire was alone in the guiding catheter. The postangioplasty angiogram was performed with only the guide wire in the guiding catheter after removing the balloon catheter from the guiding catheter. Primary success was considered to be present if all of the following conditions were met: angiographically improved stenosis (residual diameter stenosis <50% by visual esti- mate); absence of electrocardiographic (Q wave) or enzy- matic evidence (creatine kinase more than twice normal) of myocardial infarction; or need for bypass surgery. Techni- cal success was based on the first criterion alone. In mul- tivessel coronary angioplasty, technical success was con- sidered individually for each lesion.

In the first 10 months of their progressive introduction, 7F guiding catheters were used in 68 of 374 (18%) angio- plasty cases. During the last 10 months of this study, they were used in 232 (69%) of 335 patients. The reasons for using 8F catheters in 103 patients at that time were: use of Magnum or Magnarail balloons (Schneider-Europe) with a shaft diameter of 4.3F leaving insufficient space for contrast medium injection in a 7F guiding catheter5 in 78 patients; anticipated or actual use of a stent with a shaft diameter

1519

1520 Villavicencio et al. December 1891

American Heart Journal

Table I. Patient characteristics

No. 300 Age (mean f SD, range) 58 t 10, 33-84 years Sex (male/female) 255/45 Single-vessel angioplasty 233 (78%) Multivessel angioplasty 67 (22%)

2 vessels 63 3 vessels 3 4 vessels 1

Table II. Lesion distribution

No. 371 Right coronary artery 124 Left anterior descending coronary artery 118 Left circumflex coronary artery 95 Diagonal branch 23 Vein graft 9 Internal mammary artery graft 1 Left main stem 1

of 5F incompatible with 7F guiding catheters in 24 patients; and use of the kissing balloon technique in one patient.

Patients. The patient characteristics are summarized in Table I. Multivessel angioplasty was defined as angioplasty during the same procedure in >1 of the following vessels or their branches: (1) left anterior descending coronary artery except for the first diagonal branch; (2) first diagonal branch; (3) left circumflex coronary artery; (4) right coro- nary artery. A total of 371 lesions were attempted, result- ing in a mean of 1.2 lesions/patient.

Five patients were treated for an acute myocardial inf- arction, 90 for recurrent ischemia during hospitalization for acute infarction, 156 were considered to have unstable an- gina, and 49 were elective procedures for stable angina. Of the 371 sites attempted, 325 were nontotal lesions with a stenosis severity ranging from 60% to 95% (mean 86 f 11% ). Forty-six lesions were total occlusions. The le- sion distribution is listed in Table II.

Hardware. A total of 359 guiding catheters were used in 300 procedures, with a mean of 1.2 ? 0.4 catheters per pa- tient. The shapes used were: 242 Judkins, 99 Amplatz, nine El Gamal, five mammary, and four multipurpose. A total of 357 halloon catheters were used, with a mean of 1.2 * 0.4 balloons per patient. The balloon dilatation systems used were: Monorail system6 298 (83 %), standard over-the-wire system 35 (lo%), and balloon-on-a-wire 24 (7%).

All procedures were started with the balloon diameter assumed to be adequate for a good final result (no predi- latation with small balloons unless the adequate balloon failed to pass). The balloon sizes (in millimeters) were: 2.0 for six sites, 2.5 for 100 sites, 3.0 for 208 sites, 3.5 for 48 sites, 4.0 for six sites, and 4.25 for three sites.

RESULTS

Primary success in all patients with 7F guiding catheters was 95 % , and the mean residual stenosis of

successful cases was 24 t 18”( . Of the 325 nontotal lesions, 319 could be dilated through 7F guiding catheters, yielding a technical success rate of 98“, . Exchange to 8F guiding catheters was necessary in four cases (1.2 I’; ) and yielded success in two. In four unsuccessful procedures, the stenosis could not be crossed by the guide wire (in one of them, an 8F guiding catheter was tried and proved equally un- successful). In the group of nontotal lesions, there were 15 major complications (5.8 % ). Death occurred in four patients (two of whom had had emergency coronary angioplasty for cardiogenic shock during acute myocardial infarction and both died 12 and 48 hours, respectively, after the procedure). One other had a rupture of an unrecognized false ventricular aneurysm immediately after angioplasty and the last, one had an acute infarction 12 hours after a techni- cally successful angioplasty. Eleven patients (4.3 ?( ) had a myocardial infarction following angioplasty because of acute occlusion, but only five (1.9’; ) de- veloped Q waves.

Of 46 total occlusions, 33 were successfully dilated (success rate of 72%). In nine unsuccessful proce- dures, the stenosis could not be crossed by the guide wire (one of them including an exchange to an 8F catheter). Two lesions could not be crossed by the balloon and in another two the residual stenosis was >50 70. In this group, there was one death in a patient who had had emergency angioplasty for cardiogenic shock and who died 24 hours after angioplasty. One patient had a myocardial infarction because of oc- clusion of a side branch early following the procedure, and another one had emergency bypass surgery because of an intermittent thrombotic occlusion af- ter a successful angioplasty for an acute myocardial infarction. There were five patients with a significant inguinal hematoma, but none required blood trans- fusion or surgical repair.

DISCUSSION

The anecdotal use of 7F guiding catheters for cor- onary angioplasty has been described previously.7-Y In this series of 300 consecutive patients in whom coronary angioplasty was done using 7F catheters, there was a technical success rate of 98 % in nontotal lesions and 72 I’h in total occlusions, which is compa- rable to results obtained with larger guiding cathe- ters. This demonstrates the feasibility of coronary angioplasty through 7F guiding catheters in unse- lected patients. Exclusions were due to selection of large caliber angioplasty devices and not to the lesions themselves. The 7F guiding catheters provide excellent support because they can be introduced deep into the coronary arteries and additionally can be backed up against the opposite aortic wall. Thus

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the need for an 8F catheter to succeed was extremely rare in this study (0.5 %). The majority of procedures were done using the Monorail technique, which facilitates wire placement and control angiograms with the balloon catheter outside the guiding cathe- ter. With the 7F guiding catheters used in this series, angiographic visualization was unsatisfactory with nonretracted balloon catheters with a shaft larger than 4F. This has since been remedied with a second generation of 7F guiding catheters having a lumen of 1.8 mm (0.072 in). Currently, only the use of two si- multaneous balloons, a stent other than a Palmaz- Schatz type, or an atherectomy device constitutes an indication for a guiding catheter larger than 7F at our institution.

The low incidence of significant puncture site he- matomas (2 % ), none of which required blood trans- fusion or surgical correction, reflects an anticipated benefit of smaller catheters. In conclusion, we rec- ommend 7F guiding catheters as first-choice equip- ment for all conventional percutaneous transluminal coronary angioplasty procedures.

PTCA with 7F guiding catheters 1521

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