Use of Navitian microcatheter for percutaneous treatment of a chronic, severely calcified sub-occlusive lesion
Drs. Alfonso Jurado Román, Silvio Vera Vera, Artemio García, Víctor Juárez, Andrea Severo, Guillermo
Galeote, Santiago Jiménez, Raúl Moreno
Haemodinamics from Hospital Universitario la Paz, Spain.
Introduction
The existence of a sub-occlusive lesion with severe calcification is a challenge for percutaneous intervention. Lesions of this type require aggressive plaque modification prior to stent implantation. One of the therapeutic alternatives is rotational atherectomy. However, this technique requires the use of a specific guidewire (RotaWire), whose characteristics make it difficult for it to cross the lesion directly. It is therefore essential to cross the lesion with a microcatheter in order to exchange the guidewire used initially for the RotaWire.
Patient profile
- 73-year-old man with no drug allergies.
- Cardiovascular risk factors: arterial hypertension, diabetes mellitus, dyslipidaemia, overweight.
- Cardiovascular history: Functional class II effort angina.
Lesion type
- Left anterior descending artery (LAD) with good calibre and well developed, severely calcified (Figure 1) and with a high degree of tortuosity.
- Proximal subocclusive lesion, severe diffuse disease (90%) and severe calcification (Figure 2).
- Severely diseased first and second diagonal branches.
Procedure
- An antegrade procedure was performed. The left main coronary artery ostium was catheterised with a 7F EBU 3.5 mm guiding catheter.
- A Sion black polymer-jacketed guidewire was advanced into the distal LAD supported by a Navitian microcatheter. Due to the severity of the lesions, calcification and angulation, which made navigating and crossing the lesion difficult, it was decided that a rotational atherectomy should be performed.
- Advancement of the Navitian microcatheter into the distal vessel to exchange the Sion black guidewire for the RotaWire was required. Navitian managed to cross the sub-occlusive lesion, advancing distally without difficulty (Figure 3) towards the distal segment of the LAD, which allowed the exchange of the guidewires.
- A 1.25 mm olive-shaped burr was advanced and a first attempt at rotablation was made at 150,000 rpm; however, it was not possible due to the burr getting stuck proximally (Figure 4). It was possible to remove the burr by deep selective intubation of the guiding catheter and traction of the system. Subsequently, the rpm was increased to 195,000 and successful rotablation of the proximal lesion was achieved.
- The Navitian microcatheter was advanced once again and the RotaWire was exchanged for a Sion blue ES guidewire. The Navitian microcatheter was removed using a trapping balloon technique.
- Despite the success of rotational atherectomy, advancement of the balloons and stents through the artery was complex, requiring increased support with a “mother-and-child” technique using a guide extension catheter (Figure 5).
- 4 overlapping DES were implanted in a distal to proximal direction: 2.25x20 mm, 2.50x20 mm, 3.00x23 mm and 3.50X28 mm, with good final angiographic results (Figure 6).
- Good final angiographic results that were confirmed by optical coherence tomography.
Conclusion
“Due to the low crossing profile and flexibility of the Navitian microcatheter, it is a useful tool in the treatment of complex lesions (chronic occlusions, critical calcified and angulated lesions), as it supports guidewires and allows them to be exchanged safely and effectively during the procedure.”
Dr. Alfonso Jurado Román
Hospital Universitario la Paz, Spain.
