The4Frmother-childtechnique

The 4 Fr mother-child technique 4 Fr child catheter branch. This technique does not differ from the conventional mother-child technique in terms of difficulty1.n EuroIntervention Clinical experiences CASE 1 The patient was an 85-year-old man who presented with effort angina. A 6 Fr EBU 3.5 guiding catheter (TAIGA; Medtronic, Inc., Minneapolis, MN, USA) was engaged into the left coronary artery via the radial artery. Angiography showed severe narrowing from the left main trunk (LMT) to the left anterior descending artery (LAD) (Figure 2A, open arrow). After crossing a Runthrough® Hypercoat guidewire (Terumo Europe, Leuven, Belgium) to the LAD, the second Runthrough® Hypercoat guidewire was advanced to the left circumflex artery (LCX) for side-branch protection. Despite predilatation with a 3.5 ×15 mm balloon, a 3.5×23 mm Endeavor® Sprint stent (Medtronic) failed to cross the lesion owing to calcification of the proximal LAD (Figure 2B). With an anchor balloon technique, the 4 Fr child catheter was deeply advanced beyond the lesion (Figure 2C, large arrow), while the second guide- Figure 1. Mother-child system with a second guidewire for side-branch wire was retained in the LCX (small arrow). The stent could be protection.easily delivered to the lesion through the child catheter and was Figure 2. A) Baseline angiography showing severe narrowing from the left main trunk to the proximal left anterior descending artery (open arrow). B) The stent could not pass the lesion. C) The child catheter was advanced beyond the lesion (large arrow) with the second guidewire in the side branch (small arrow). D) The stent was delivered through the child catheter (large arrow) while the second guidewire was retained in the side branch (small arrow). E) After stenting, kissing balloon dilatation was performed. F) An additional stent was deployed in the proximal lesion (arrowheads).2012;8:634-637 n EuroIntervention 2012;8: 634-637deployed from the LMT to the proximal LAD (Figure 2D). After the third guidewire (Fielder FC; Asahi Intecc, Aichi, Japan) was crossed to the jailed LCX through the stent strut, the second guidewire was retrieved and kissing balloon dilatation was performed using a 3.5 mm and a 2.0 mm balloon (Figure 2E). Subsequently, an addi- tional 3.5×9 mm Endeavor® Sprint stent was deployed for residual stenosis in the proximal LMT (Figure 2F, arrowheads). CASE 2 The patient was a 62-year-old man undergoing long-term haemodi- alysis who presented with effort angina. A 7 Fr guiding catheter (SAL 1.0 SH, Launcher; Medtronic) was engaged into the right coronary artery (RCA) via the femoral artery. Baseline angiography revealed subtotal occlusion in the bifurcation of the atrioventricular (AV) and the posterior descending (PD) branches (Figure 3A, open arrow). A Wizard 1.0 guidewire (Japan Lifeline Co. Ltd, Tokyo, Japan) with FineCross™ microcatheter (Terumo) was advanced into the AV branch, and a Runthrough Hypercoat guidewire was advanced into the PD branch. Despite predilatation of both branches, a 2.5×24 mm Endeavor Sprint stent failed to cross the mid RCA. By deeply advancing a 4 Fr child catheter (Figure 3B, large arrow), the Endeavor Sprint stent was easily delivered and implanted in the AV branch across the PD branch. After successful re-crossing of the guidewire, the stent strut and the proximal PD branch were dilated. However, the second Endeavor Sprint stent (2.5×24 mm) could not pass the mid RCA. Thus, the 4 Fr child catheter was again advanced close to the lesion (Figure 3C, large arrow). This time, the protective guidewire was intentionally left in the AV branch (small arrow). Through the 4 Fr child catheter, the second stent could be easily delivered and was implanted into the jailed PD branch (Figure 3D). With the protective guidewire in place, the Wizard guidewire easily re-crossed to the AV branch through the strut of the second stent. Final kissing balloon dilatation was performed using two 2.5×15 mm balloons (Figure 3E). Finally, an additional 3.0×18 mm Endeavor Sprint stent was deployed in the mid RCA, using the 4 Fr mother-child technique, followed by post-dilatation with a 3.25×12 mm balloon (Figure 3F, arrowheads).DiscussionIn these two cases, delivery of coronary stents was difficult using the conventional technique because of severe calcification and/or tortu-osity of the target vessel. Moreover, protecting the large side branches Figure 3. A) Baseline angiography showing proximal tortuosity and subtotal occlusion (open arrow) in the right coronary artery (RCA). B) The stent was implanted in the atrioventricular (AV) branch across the posterior descending (PD) branch by using a child catheter (large arrow). C) The child catheter (large arrow) was advanced to the distal RCA while the second guidewire was retained in the AV branch (small arrow). D) The second stent was implanted into the PD branch with the protective guidewire in the AV branch (small arrow). E) After stenting, kissing balloon dilatation was performed. F) An additional stent was deployed in the proximal lesion (arrowheads). 636 4 Fr child catheter seemed crucial for procedural success. We thus used a 4 Fr mother- child technique with side-branch protection. Placing a second, pro- tective guidewire in the side branch during main-branch stenting is a a child catheter because of the limited space between the child and mother catheters. Second, the 4 Fr child catheter cannot accommo-date two balloon catheters2. Therefore, before the final kissing bal-nEuroIntervention safe and effective approach to prevent occlusion. Although other loon inflation, the 4 Fr child catheter should be retrieved from the mother-child systems, including the 5-in-6 and 5-in-7 systems with a mother guiding catheter. Third, the operator should be cautious 5 Fr child catheter2 and the 6-in-7 system with the GuideLiner cath-about the risk of air embolism while advancing the balloon/stent eter (Vascular Solutions, Inc., Minneapolis, MN, USA)3, can also through a child catheter. accommodate a second guidewire, deep insertion of large child cath- eters easily compromise coronary flow. Furthermore, in the 5-in-6 References and 5-in-7 systems, the second guidewire does not pass the space 1. Takeshita S, Shishido K, Sugitatsu K, Okamura N, Mizuno S, between the two catheters. Thus, the wire has to go through the inner Yaginuma K, Suenaga H, Tanaka Y, Matsumi J, Takahashi S, lumen of the child catheter, the retrieving of which becomes some-Saito S. In vitro and human studies of a 4F double-coaxial what cumbersome because it will require two extension wires.technique (“mother-child” configuration) to facilitate stent implan-Currently, two different Japanese manufacturers –Terumo and tation in resistant coronary vessels. Circ Cardiovasc Interv. Asahi Intecc– produce 4 Fr child catheters. The outer diameter of 2011;4:155-61. the Cokatte catheter from Asahi Intecc is slightly larger than that of 2. Mamas MA, Eichhöfer J, Hendry C, El-Omar M, Clarke B, the Kiwami catheter from Terumo (1.50 and 1.43 mm, respec-Neyses L, Fath-Ordoubadi F, Fraser D. Use of the Heartrail ll cath-tively). Although the difference in the outer diameter is <0.1 mm, eter as a distal stent delivery device; an extended case series. the Cokatte catheter cannot be inserted into a 6 Fr mother guiding EuroIntervention. 2009;5:265-71. catheter with the second, protective guidewire. 3. Mamas MA, Fath-Ordoubadi F, Fraser D. Distal stent delivery This technique has several limitations. First, the second guide-with Guideliner catheter: first in man experience. Catheter wire should be advanced into the side branch before introducing Cardiovasc Interv. 2010;76:102-11.2012;8:634-637 637