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887
Technical
Use of the Balloon on a Guidewire Conventional Angioplasty Jeffrey
S. Pollak,1
Stanley
G. Cooper,
and Donald
F. Denny,
Standard balloon angioplasty involves crossing a stenosis by a guidewire and subsequently advancing a catheter over the wire. Various instruments have been developed to aid in these two steps, including steerable wires and tapered catheters that predilate lesions to permit easier passage of the balloon catheter. Occasionally, the stenosis is sufficiently tight and rigid that it will not allow a catheter to track over the wire. In this report, we describe a method of predilating such lesions with a balloon on a guidewire, after which a larger conventional balloon catheter can be used.
Materials
and
Methods
The balloon on a guidewire (USCI Probe: USCI, Billenca, MA, and TEGwire: Medi-tech, Watertown, MA) consists of variously sized balloons incorporated onto the end of a 0.035- or 0.038-in. wire with a thin platinum-tipped steerable wire attached to the tip. After a selective catheter is placed at the stenosis, the guidewire-balloon is advanced across it and inflated. Subsequently, the balloon is deflated and the catheter is advanced over this wire, or the balloon is removed and a conventional wire is used to recross the lesion. The latter may be necessary because it may be difficult to withdraw the guidewireballoon through a 0.038-in. tapered catheter, especially for balloon sizes greater
than 3 mm. A nontapered
guiding
catheter
can be used
to facilitate removal. A larger balloon can then be used to dilate the stenosis to the desired vessel diameter.
Case
Example
A 76-year-old woman with severe hypertension angioplasty 5 weeks after outpatient angiography Received I
was admitted for revealed a severe
as an Adjunct
Note
to
Jr.
ostial stenosis of the right renal artery (Fig. 1A). By use of a right femoral approach, the stenosis was easily crossed with a 0.035-in. angled
Glidewire
(Terumo,
MA) and a 0.035-in.
Tokyo;
Wholey
wire
distributor: (Advanced
Medi-tech,
Watertown,
Cardiovascular
Systems,
Mountain View, CA), but these could not be followed by a 5.5-French Cobra catheter, a 5.5-French Simmons catheter, or a 6.5-French Simmons catheter, used for greater stiffness (all manufactured by Cook, Bloomington, IN). Fluoroscopically, advancement of the catheter tip was shown to be prevented by the stenosis in each case. Finally, a 3-mm-diameter balloon on a wire (USCI Probe) was ad-
through the 6.5-French Simmons catheter. It easily crossed the lesion and was successfully inflated (Fig. 1 B); however, although the Simmons catheter now easily slipped past the lesion, the angioplasty wire could not be withdrawn into the lumen of the catheter because of the profile of the balloon. Therefore, both were removed through a sheath. The Simmons catheter was reinserted and now followed a 0.035-in. Glidewire across the stenosis. Over an exchange vanced
wire,
a 6 mm
by 2 cm
balloon
catheter
was
placed
for the
final
dilatation. A postangioplasty aortogram showed a widely patent vessel with an intimal crack. The patient’s blood pressure normalized by that evening and remained improved on reduced antihypertensive medication
at 2 months.
Discussion
The initial success rate for noncoronary angioplasty is approximately 90% [1 1’ with a range of 77-95% for the renal arteries [1 -4] and approximately 90% for the celiac and superior mesenteric arteries [5]. Although the majority of initial failures are probably plications, a fraction
related to inadequate dilatation are related to impassable lesions,
or comdespite
March 2, 1990: accepted after revision April 11 , 1990.
All authors: Department
AJR 155:887-888,
October
of Radiology, Yale University School of Medicine, P.O. Box 3333, New Haven, CT 0651 0. Address reprint 1990 0361 -803X/90/1554-0887
© American
Roentgen
Ray Society
requests to J. S. Pollak.
888
POLLAK
ET
AL.
AJR:155,
Fig. 1.-A,
Diagnostic
aortogram
October 1990
reveals
se-
Downloaded from www.ajronline.org by 109.161.209.200 on 11/16/15 from IP address 109.161.209.200. Copyright ARRS. For personal use only; all rights reserved
vera ostial stenosis of right renal artery. B, Angioplasty wire inflated across renal tery stenosis.
A
ar-
B
the use of steerable guidewires and low-profile balloons. When a wire can be advanced through a lesion but the catheter will not follow, predilatation with a balloon on a wire should prove to be useful, as it was here. It is doubtful that any other conventional method would have worked in these patients. The use of a coaxial catheter over a smaller wire would not have dilated the stenosis any more than the initial 0.035-in. wire did, and the use of an axillary approach for a more favorable angle from the aorta would most likely have encountered buckling of the catheter along the course of the vessels in the chest. Furthermore, the 6.5-French Simmons catheter used did not uncoil; it simply could not be advanced, implying that there would have been no directional advantage from the axillary route. One disadvantage was the inability of
a tapered
catheter
to follow
over the wire once the balloon
ciently dilated to allow passage of the 5.5-French catheter that had not been able to advance previously. This was then exchanged for a 6-mm balloon catheter. Of greater concern, in a case in which a TEGwire was being used as the principal balloon for a distal popliteal lesion, the proximal part of the wire fractured, presumably owing to torsional stress. Fortunately, this part of the wire was outside of the patient. Indeed, the USCI Probe has been removed from the market. Keeping in mind the need for greater experience with the angioplasty wire, it appears that it will have a useful, adjunctive role in the dilatation of larger vessels.
REFERENCES
had been inflated and deflated. This meant that we had to recross the angioplasty site after removing the initially placed
1 . Becker GJ, Katzen 1989;170:921 -940
BT, Dake
wire
2. Klinge
Puijlaert
and
catheter.
Although
this
is of concern,
we
feel
that
the careful use of a flexible, steerable wire limits the risks of dissection and occlusion. Nontapered catheters are a solution to this problem because their larger end holes should allow them to advance over the wire. The angioplasty guidewire has recently been described [6, 7]; its small size and low profile make it particularly useful in negotiating tight lesions in small vessels. However, a need for caution is indicated by two problems we encountered with these devices. While using the technique described here to dilate two adjacent superior mesenteric artery stenoses, the angioplasty wire developed a leak along the shaft proximal to the balloon. Fortunately, the lesions had already been suffi-
J, Mali WPT,
MD. CBA,
Noncoronary Geyskes
angioplasty.
GG, Becking
MAM. Percutaneous transluminal renal angioplasty: results. Radiology 1989;171 :501 -506
Radiology WB,
Feldberg
initial and long-term
3. Sos TA, Saddekni 5, Sniderman KW, et al. Renal artery angioplasty: techniques and early results. Urol Radiol 1982;3:223-23i 4. Tegtmeyer CJ. Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery: results and long term follow-up. Radiology 1984:153:77-84 5. Odumy A, Sniderman KW, Colapinto RF. Intestinal angina: percutaneous transluminal angioplasty of the celiac and superior mesenteric arteries. Radiology 1988;167:59-62 6. Myler AK, Mooney MA, Stertzer SH, Clark DA, Hidalgo BO, Fishman J.
The balloon on a wire device: a new ultra-low profile coronary angioplasty system/concept. Cathet Cardiovasc Diagn 1988:14:135-140 7. Tegtmeyer Radiology
CJ. Guide wire angioplasty 1988;169:253-254
balloon
catheter:
preliminary
report.
887
Technical
Use of the Balloon on a Guidewire Conventional Angioplasty Jeffrey
S. Pollak,1
Stanley
G. Cooper,
and Donald
F. Denny,
Standard balloon angioplasty involves crossing a stenosis by a guidewire and subsequently advancing a catheter over the wire. Various instruments have been developed to aid in these two steps, including steerable wires and tapered catheters that predilate lesions to permit easier passage of the balloon catheter. Occasionally, the stenosis is sufficiently tight and rigid that it will not allow a catheter to track over the wire. In this report, we describe a method of predilating such lesions with a balloon on a guidewire, after which a larger conventional balloon catheter can be used.
Materials
and
Methods
The balloon on a guidewire (USCI Probe: USCI, Billenca, MA, and TEGwire: Medi-tech, Watertown, MA) consists of variously sized balloons incorporated onto the end of a 0.035- or 0.038-in. wire with a thin platinum-tipped steerable wire attached to the tip. After a selective catheter is placed at the stenosis, the guidewire-balloon is advanced across it and inflated. Subsequently, the balloon is deflated and the catheter is advanced over this wire, or the balloon is removed and a conventional wire is used to recross the lesion. The latter may be necessary because it may be difficult to withdraw the guidewireballoon through a 0.038-in. tapered catheter, especially for balloon sizes greater
than 3 mm. A nontapered
guiding
catheter
can be used
to facilitate removal. A larger balloon can then be used to dilate the stenosis to the desired vessel diameter.
Case
Example
A 76-year-old woman with severe hypertension angioplasty 5 weeks after outpatient angiography Received I
was admitted for revealed a severe
as an Adjunct
Note
to
Jr.
ostial stenosis of the right renal artery (Fig. 1A). By use of a right femoral approach, the stenosis was easily crossed with a 0.035-in. angled
Glidewire
(Terumo,
MA) and a 0.035-in.
Tokyo;
Wholey
wire
distributor: (Advanced
Medi-tech,
Watertown,
Cardiovascular
Systems,
Mountain View, CA), but these could not be followed by a 5.5-French Cobra catheter, a 5.5-French Simmons catheter, or a 6.5-French Simmons catheter, used for greater stiffness (all manufactured by Cook, Bloomington, IN). Fluoroscopically, advancement of the catheter tip was shown to be prevented by the stenosis in each case. Finally, a 3-mm-diameter balloon on a wire (USCI Probe) was ad-
through the 6.5-French Simmons catheter. It easily crossed the lesion and was successfully inflated (Fig. 1 B); however, although the Simmons catheter now easily slipped past the lesion, the angioplasty wire could not be withdrawn into the lumen of the catheter because of the profile of the balloon. Therefore, both were removed through a sheath. The Simmons catheter was reinserted and now followed a 0.035-in. Glidewire across the stenosis. Over an exchange vanced
wire,
a 6 mm
by 2 cm
balloon
catheter
was
placed
for the
final
dilatation. A postangioplasty aortogram showed a widely patent vessel with an intimal crack. The patient’s blood pressure normalized by that evening and remained improved on reduced antihypertensive medication
at 2 months.
Discussion
The initial success rate for noncoronary angioplasty is approximately 90% [1 1’ with a range of 77-95% for the renal arteries [1 -4] and approximately 90% for the celiac and superior mesenteric arteries [5]. Although the majority of initial failures are probably plications, a fraction
related to inadequate dilatation are related to impassable lesions,
or comdespite
March 2, 1990: accepted after revision April 11 , 1990.
All authors: Department
AJR 155:887-888,
October
of Radiology, Yale University School of Medicine, P.O. Box 3333, New Haven, CT 0651 0. Address reprint 1990 0361 -803X/90/1554-0887
© American
Roentgen
Ray Society
requests to J. S. Pollak.
888
POLLAK
ET
AL.
AJR:155,
Fig. 1.-A,
Diagnostic
aortogram
October 1990
reveals
se-
Downloaded from www.ajronline.org by 109.161.209.200 on 11/16/15 from IP address 109.161.209.200. Copyright ARRS. For personal use only; all rights reserved
vera ostial stenosis of right renal artery. B, Angioplasty wire inflated across renal tery stenosis.
A
ar-
B
the use of steerable guidewires and low-profile balloons. When a wire can be advanced through a lesion but the catheter will not follow, predilatation with a balloon on a wire should prove to be useful, as it was here. It is doubtful that any other conventional method would have worked in these patients. The use of a coaxial catheter over a smaller wire would not have dilated the stenosis any more than the initial 0.035-in. wire did, and the use of an axillary approach for a more favorable angle from the aorta would most likely have encountered buckling of the catheter along the course of the vessels in the chest. Furthermore, the 6.5-French Simmons catheter used did not uncoil; it simply could not be advanced, implying that there would have been no directional advantage from the axillary route. One disadvantage was the inability of
a tapered
catheter
to follow
over the wire once the balloon
ciently dilated to allow passage of the 5.5-French catheter that had not been able to advance previously. This was then exchanged for a 6-mm balloon catheter. Of greater concern, in a case in which a TEGwire was being used as the principal balloon for a distal popliteal lesion, the proximal part of the wire fractured, presumably owing to torsional stress. Fortunately, this part of the wire was outside of the patient. Indeed, the USCI Probe has been removed from the market. Keeping in mind the need for greater experience with the angioplasty wire, it appears that it will have a useful, adjunctive role in the dilatation of larger vessels.
REFERENCES
had been inflated and deflated. This meant that we had to recross the angioplasty site after removing the initially placed
1 . Becker GJ, Katzen 1989;170:921 -940
BT, Dake
wire
2. Klinge
Puijlaert
and
catheter.
Although
this
is of concern,
we
feel
that
the careful use of a flexible, steerable wire limits the risks of dissection and occlusion. Nontapered catheters are a solution to this problem because their larger end holes should allow them to advance over the wire. The angioplasty guidewire has recently been described [6, 7]; its small size and low profile make it particularly useful in negotiating tight lesions in small vessels. However, a need for caution is indicated by two problems we encountered with these devices. While using the technique described here to dilate two adjacent superior mesenteric artery stenoses, the angioplasty wire developed a leak along the shaft proximal to the balloon. Fortunately, the lesions had already been suffi-
J, Mali WPT,
MD. CBA,
Noncoronary Geyskes
angioplasty.
GG, Becking
MAM. Percutaneous transluminal renal angioplasty: results. Radiology 1989;171 :501 -506
Radiology WB,
Feldberg
initial and long-term
3. Sos TA, Saddekni 5, Sniderman KW, et al. Renal artery angioplasty: techniques and early results. Urol Radiol 1982;3:223-23i 4. Tegtmeyer CJ. Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery: results and long term follow-up. Radiology 1984:153:77-84 5. Odumy A, Sniderman KW, Colapinto RF. Intestinal angina: percutaneous transluminal angioplasty of the celiac and superior mesenteric arteries. Radiology 1988;167:59-62 6. Myler AK, Mooney MA, Stertzer SH, Clark DA, Hidalgo BO, Fishman J.
The balloon on a wire device: a new ultra-low profile coronary angioplasty system/concept. Cathet Cardiovasc Diagn 1988:14:135-140 7. Tegtmeyer Radiology
CJ. Guide wire angioplasty 1988;169:253-254
balloon
catheter:
preliminary
report.
