30.

3
Guide catheter extensions

Emmanouil S. Brilakis, MD, PhD

 PCI: the steps
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 Equipment categories

1. Sheaths 1. Guideliner V3
2. Catheters 2. Trapliner
3. Guide extensions 3. Guidezilla II
4. Support catheters
5. Y connectors
4. Telescope
6. Microcatheters 5. Guidion
7. Guidewires 6. Heartrail 5 in 6 system
8. Embolic protection devices
9. Balloons
10.Atherectomy
11. Laser
 Guide catheter extensions

Trapliner / Guideliner Guidezilla

Telescope
Guideliner
 Trapliner
Balloon
inflated to
“trap” the
guidewire
Guidezilla
Telescope
Guidion
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
Approach to “balloon uncrossable” lesion
“Balloon Uncrossable” lesion

1. Small balloon
2. Rupture balloon in vessel (grenadoplasty) 1st line

Guide catheter
3. Increase support 2nd line
Wire

4. Microcatheter 3rd line

5. Wire “cutting” or puncture
9. Combinations
6. Laser 4th line
7. Atherectomy

External crush
8. Subintimal techniques 5th line
Distal anchor
Getting support: Guideliner
“Swan neck” maneuver

Mamas et al. CCI 2011

 Predilation
– balloon
rupture

next step?

TIP
Severe
calcification
increases risk for
perforation
 Unable to
deliver
2.80x19 mm

Graftmaster

TIP
Delivery of covered stents
can be very challenging
 Covered
stent
through
Guideliner

TIP
Graftmaster stents can fit
within an 8 Fr guide
catheter extension
Perforation
sealed
Second covered stent delivery
with GuideLiner

CTOmanual.org – case 89
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
Wire to help
engagement
Guide extension to
help engagement
Guide extension to
help engagement of
anomalous RCA
Tandem bifurcations
 Balloon assisted
GuideLiner advancement
Better visualization
reveals more clear
anatomy
Predilation
Stent delivery
Stent deployment
Final result
Final result

Procedural time: 56 min

Fluoroscopy time: 14.3 min
AK: 1629 mGy
Contrast Volume: 220 ml
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
D
Guide extension

Courtesy Dr. Roberto Garbo

 Guide extension

E
Courtesy Dr. Roberto Garbo
 Guideliner
Cut Rotablator
shaft

entrapped
burr

Courtesy Dr. Amir Ravandi

 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
RCA CTO
 Guide extensions can facilitate:

1. Equipment delivery
2. Coronary engagement
3. Thrombectomy
4. Retrieval of entrapped
equipment
5. Reverse CART
6. ADR
7. KAM-snare
How to create a “homemade” snare

Courtesy: Dr. Kambis Mashayekhi

How to create a “homemade” snare

Courtesy: Dr. Kambis Mashayekhi

Guide extension alternative: deep intubation
Cannot deliver stent Deep guide intubation
Stent delivered
Stent deployed Postdilation
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery: GuideLiner V3
Balloon
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter Guidewire

7. Proximal to distal stenting feasible

8. Compatibility
Wire-
Towel
balloons-
preventing
stents
wrapping of
wire with
Guide guide catheter
catheter extension
extension push rod
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
How to deliver a
guide catheter
extension

Balloon-assisted
tracking

aka

Inchworming
TrapLiner
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
 BAT: Balloon-
Assisted Tracking

Courtesy: Basem Elbarouni, MD

 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
Finn et al. Circ Cardiovasc Interv. 2016;9:e003961
Finn et al. Circ Cardiovasc Interv. 2016;9:e003961
Finn et al. Circ Cardiovasc Interv. 2016;9:e003961
 Guide extensions: tips + tricks
1. Pushrod under towel
2. Delivery:
• Inchworming (preferred)
• BAT, distal anchor
3. Advance wires under fluoro
4. Do not advance proximal collar outside guide
5. Trapping is difficult
6. Mother-daughter-granddaughter
7. Proximal to distal stenting feasible
8. Compatibility
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation
 Equipment deformation/loss

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

 Guide
extension –
wire damage
 Telescope
guide
extension –
wire damage
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation
Deep-seated Guideliner
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation
Hold your Guideliner during injections!
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation
 CTOmanual.org: case 131

• On removing Trapliner from pt, device missing from/separated from shaft

• luckily in tuohy
 Guide extensions: complications
1. Equipment deformation
• Advancement
• Withdrawal
2. Dissection
3. Thrombus formation
4. Distal migration
5. Fracture
6. Longitudinal stent deformation