A 7F (6 in 7) GLC was then gently advanced into the LAD over an inflated balloon for approximately 3 cm across the proximal CTCA. The BVS could not be delivered to the lesion site and was withdrawn. Stenting of LAD was attempted using a 2.5 × 28 mm BVS through a 7F extra back up GC and over an All Star™ extra support wire (Abbott Vascular, Santa Clara, USA) and “Buddy Wire”. The lesion was then fully pre-dilated with 2.5 × 12 mm non-compliant (NC) balloon to 24 atm with no residual stenosis. The proximal LAD was also calcified and had two bends ( Fig. 1a and b.) Rotational atherectomy of LAD was performed with a 1.5 mm burr. Coronary angiogram (CAG) revealed single vessel 80% calcified mid-Left anterior descending artery (LAD) stenosis. These observations would be even more vital when delivering BVS through 6F GC via radial route in CTCA.Ī 72-year-old gentleman with Diabetes and hypertension presented with exertional angina of 3 months duration.
#Guideliner series#
We therefore, describe for the first time the technical considerations for the use of GLC to deliver Absorb through the series of four cases. As the BVS is a large profile device, certain problems were encountered during its use with GLC. The use of the GuideLiner™ catheter (GLC) a rapid exchange, coaxial, guide catheter extension device 2 finally enabled successful implantation of BVS. Of these the BVS failed to deliver in four cases despite all efforts and tricks outlined above. From Jan 2013 to Sep 2013, out of 177 “real world” lesion treated with BVS, 78 lesions were calcified or/and had proximal CTCA. Various ‘tricks’, which have been well described to overcome failure of stent delivery, like better GC support and ‘deep’ intubation, ‘extra support’ wires and ‘buddy wires’, may also occasionally fail to deliver a BVS across difficult CTCA. Once withdrawn, a new BVS has to be taken for the second attempt as per the Instruction for Use (IFU Absorb, Abbott Vascular, Santa Clara, USA). Additionally if there is a failure to deliver the BVS across the lesion, then the high profile ‘invisible device’ would have to be withdrawn into the Guide Catheter (GC) with a risk of device dislodgement. Calcified, tortuous coronary arteries (CTCA) and lesions pose a challenge to the delivery and implantation of the BVS, because of its larger profile (the 2.5 mm and 3.0 mm diameter BVS has a crossing profile of ≤0.060″ and the 3.5 mm diameter BVS has a crossing profile of ≤0.065″). Based on the first in man studies, 1 its subsequent approval in many countries has lead to its increasing use in ‘real world’ patients with complex coronary artery disease, which had been excluded from the previous studies. The Absorb™ Bioresorbable Vascular Scaffold (BVS) represents a fascinating advancement in stent technology for treatment of significant coronary stenosis with the benefits of ‘best in class’ metallic drug eluting stents (DES) in the short term and without leaving behind a permanent metallic implant in the long term. We have therefore discussed the ‘lessons and learnt’ and “salient practice points” to enable successful delivery of BVS through the GLC.
Because the BVS is a large profile device, certain difficulties were encountered in delivering it through the GLC, which were finally overcome. We report for the first time four cases of use of guideliner catheter to successfully overcome failed delivery of BVS to the lesion site through proximal CTCA, calcified and tortuous coronary artery (CTCA) lesions treated with Absorb™ BVS. “Guide Liner” catheter (GLC) had to be finally used to resuccessfully deliver and implant BVS to the lesion site. In four of these, despite adequate lesion bed preparation, appropriate guiding catheter support and use of buddy wires, the BVS failed to track through the proximal calcified and tortuous coronary anatomy (CTCA). In our series of 177 real world patients (223 lesions) who underwent Absorb Bioresorbable Vascular Scaffold (BVS) implantation, 78 lesions were calcified and tortuous lesions.
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