PERCUTANEOUS CORONARY INTERVENTIONS

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AL-1 guide catheter use for tortious right coronary artery

Operators:Associate Prof. Dr. Mutlu Vural
Nurse: Zuhal Bağış

Bağcılar Education and Research Hospital

Introduction

We authomaically prefer standard JL 4.0 left guide for acute anterior MI and JR 4.0 right guide for acute anterior MI respectively. This is the case abroad. The department heads do not want to use extra support guiding catheters except experienced interventional cardiologists. Starting with safer standard JL and JR catheters, they are told to switch to compensatory materials in their hands, such as an extension catheter when they have a difficulty. If you have plenty of materials, the standard guide catheters are suitable, but I always give importance to the guiding catheter “backup” support in my attempts. I always start with diagnostic catheters in an acute MI. I select the guide catheter according to the condition of the vessel. That’s our case yesterday.

Case presentation

A 60-year-old male with acute inferior MI and rapid ventricular response AF was admitted to our laboratory yesterday for primary PCI . There are no features in the left system, but the right coronary is quite curved with some lesions (Video 1 and Video 2). We started with the AL-1 guide catheter. Even the floppy wire support was enough. I pay attention to the resistance to deliver the material and the guide catheter tip in the ostium of RCA. When you apply a medium continuous push level when there is resistance, the material moves spontaneously in the contraction and relaxation cycle of the heart. We have deliverred a 3.5×24 mm stent following a 3.0×20 mm predilatation balloon (Video 3). I never give an uncontrolled power in a short time. The AL-1 guide catheter was fully inserted into the vessel bed while distal 3.5×24 mm stent balloon was withdrawn (Video 4). The catheter spontaneously returned to its position when the proximal 4.0×29 mm BMS stent is pushed and the stent was implanted in this position (Video 6). The middle region was observed when from RAO projection after pullin back the wire. Stenosis was not significant, but the fold was shown in two axes (Video 6). When the final result was satisfactory, the procedure was concluded (Video 7). After 3 hours of the procedure, we performed control angiography due to persisting chest pain and the stent was patent (the proximal and mid portion were much better in this situation as the total amount of vasopressor stress decreased).

Tips&Tricks
1. AL-1 is risky. In another case 12 years ago, one of my patient had developed a dissection at the catheter tip. After stenting, it is resolved. But I did not encounter such a problem in the period when I was experienced and avoided sudden withdrawal movements. When removing the catheter, it is necessary to remove the catheter by pushing and turning under the scopy. I prefer to pull back the guide catheter into the aorta over the guidewire which is already inside and the withdraw whole system. Those without experience should not use AL-1. You should take an extension catheter and replace the wire with extra support wires through a microcatheter.
2. In another case, we switched from AR-2 to AL-1. In this case, I took Al-1 directly. To see that case please click here http://www.kompleks-pkg.com/vaka/kalsifik-rcaya-primer-pkg/

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Video 7

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