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Emergency coronary angioplasty with stenting using Cordis® diagnostic coronary catheters when there is difficulty in engaging guide catheters and bench evaluation of diagnostic and guide catheters
Angioplastia coronária de emergência com stents usando cateteres coronários diagnósticos no contexto de entubação difícil pelos cateteres-guia e avaliação prática de cateteres guias e de diagnóstico
Mark Christopher Arokiaraj
Cardiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
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DC: diagnostic catheter; GC: guide catheter.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Difficulty in engaging standard guide catheters when performing angioplasty can be life-threatening in acute coronary syndromes (ACS), especially in acute myocardial infarction (MI), in which the speed and success of the procedure with limited contrast usage are paramount<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1–3</span></a> and shorter fluoroscopy and procedural times are desirable. In such settings, prolonged manipulation of guide catheters is frequently required, or sizes or models of multiple guide catheters need to be changed. In general, diagnostic catheters tend to engage better than guide catheters, due to better stiffness and recoil properties.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> In the setting of MI, this can have significant consequences.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Balloon angioplasties performed using diagnostic catheters have been reported. There is one report of two cases of stenting with diagnostic catheters,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> and two of routine primary angioplasty or in acute coronary syndromes predominantly through radial access.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6,7</span></a> We present a retrospective study of 34 patients who underwent angioplasty using diagnostic catheters as an urgent measure when there was difficulty in engaging guide catheters. The aim of the study was to evaluate the role of Cordis<span class="elsevierStyleSup">®</span> INFINITI diagnostic catheters in reducing procedure time and difficulty in catheter manipulations, and in improving safety by reducing contrast load and hence procedural complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Engagement of diagnostic catheters</span><p id="par0015" class="elsevierStylePara elsevierViewall">A standard angiogram was performed and angioplasty was planned in all cases of ACS. Difficulty in engaging standard guide catheters was encountered in 34 cases. The femoral route was the preferred method for the operator in primary angioplasty for ACS. Difficulty in engaging guide catheters was defined as difficulty with two or more standard guide catheters in engaging the target artery with reasonable manipulations using discretion. The catheters chosen were predominantly Judkins catheters. The operator (i.e. the author) performed the procedures. Only 6F guide catheters were used in all cases. For the left coronaries, a 3.5 cm Judkins Left (JL) was used initially. If engagement failed, a 4.0, 4.5 or 5.0 cm JL was tried, depending on aortic dilation and curvature. In younger patients and with a less arched aorta, a 3.0 Judkins Left (JL) was used for engagement of the ostia. If this failed, Cordis<span class="elsevierStyleSup">®</span> Extra Backup (XBU) catheters of similar dimensions were tried. For the right coronary system a 3.5 cm JR was used in the majority of cases. If engagement failed, a Cordis<span class="elsevierStyleSup">®</span> JR 4 or Cordis<span class="elsevierStyleSup">®</span> Amplatz Right (AR) 1 or 2 was used, depending on the patient's age and the shape of the aorta. If the catheter was approaching the ostium, another JR 3.5 was tried, depending on the procedural circumstances. Also, in all these cases insertion of a 0.014″ wire was attempted into the coronaries even when the guide catheter did not engage or was placed near the coronary ostium. However, in all cases, the diagnostic catheters engaged very well during the initial angiogram, so the same 6F Cordis<span class="elsevierStyleSup">®</span> INFINITI diagnostic catheter was used to perform angioplasty. <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows angiograms of angioplasty performed using diagnostic catheters. The diagnostic catheters have a luminal diameter of 1.4 mm, and the guide catheters have a luminal diameter of 1.8 mm.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The mean age of the patients was 60±14 years, and 27 were male. The main causes of difficulty in engaging guide catheters encountered were tortuosity of iliofemoral arteries (12), mildly dilated aorta (9), slightly posterolateral origin of the right coronary (5), tortuous abdominal-thoracic aorta (4), and high origin of the left main artery (3). However, a combination of multiple factors in various degrees was the reason for difficulty in engaging guide catheters more often than any isolated cause. All injections were given by hand only; a power injector was not used for coronary visualization in any of the cases. Two patients had cardiogenic shock, in one of whom intra-aortic balloon counterpulsation was used, and the other patient was managed with inotropes. No mortality was encountered during the procedures. BMW (Abbott) wires were used in 30% of cases, All Star (Abbott) in 57.5% of lesions and Runthrough NS (Terumo) in the remaining 12.5%.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Lesion characteristics</span><p id="par0025" class="elsevierStylePara elsevierViewall">The lesions were discrete and critical, and caused 90-100% stenosis by visual assessment, predominantly with associated soft clots. In 16 cases, angioplasty was performed in the proximal left anterior descending (LAD) artery, eight in the circumflex artery and in the right coronary artery (RCA) in the other 10 patients. Calcified lesions were seen in six cases, three of them heavily calcified.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Stent and balloon characteristics</span><p id="par0030" class="elsevierStylePara elsevierViewall">The stent length used was between 12 and 20 mm in 27 patients, 24 mm in four patients, 28 mm in two cases, and 8 mm in one patient. A total of 40 stents were used in these 34 cases. Direct stenting was the preferred technique. It was left to the operator's discretion to use the shortest possible stent length to avoid redundancy. In nine cases predilatation was performed. Tazuna semi-compliant balloons (2 mm×10 mm) were used in three cases, a 1.5×10 mm Sprinter balloon in one patient and Fast Track semi-compliant balloons (2 mm×10 mm and 2.5 mm×10 mm) were used in four other cases. The stent widths mainly ranged from 2.25 mm to 3.0 mm. In four cases, 3.5 mm stents were deployed without difficulty. The balloons were easily withdrawn into the catheter after stent deployment. Post-dilatation was performed in three cases with 3 mm×12 mm Fast Track semi-compliant balloons and a 2.75 mm×10 mm iTrack balloon.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Catheter testing</span><p id="par0035" class="elsevierStylePara elsevierViewall">Further catheter testing was performed in vitro to study the mechanisms of engagement by evaluating catheter pushability and trackability characteristics and by three-point bending and distal tip flexion tests. Eleven catheters were selected and analyzed in the testing laboratory. Lists of the diagnostic and guide catheters are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>. For three-point bending and distal tip flexion tests five catheters – diagnostic JL and JR, 6F JL and JR guide catheters and 5F XBU – were selected (<a class="elsevierStyleCrossRef" href="#sec0135">Supplementary Table 3</a>). The catheters used for distal tip flexion testing are listed in <a class="elsevierStyleCrossRef" href="#sec0135">Supplementary Table 4</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Intravascular ultrasound catheter evaluation</span><p id="par0040" class="elsevierStylePara elsevierViewall">The OptiCross (Boston Scientific) intravascular ultrasound (IVUS) catheter was chosen, and the ability of this catheter to pass through the diagnostic catheters was assessed in both JL and JR 6F catheters.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Procedure</span><p id="par0045" class="elsevierStylePara elsevierViewall">All the diagnostic catheters used were 6F Cordis<span class="elsevierStyleSup">®</span>. The angioplasty procedure with stenting was successfully performed using diagnostic catheters, stents being easily placed in the lesion site in the coronaries. In total, 40 stents were used: Endeavor Resolute (1), Excel (6), Biomatrix Flex (1), Endeavour Sprint (11), Onyx (1), Ultimaster (4), Nobori (6), Yukon Choice PC Flex (5), Resolute Integrity (3) and Xience Alpine (2). A slight dampening of pressure tracings was observed during the procedure except in newer-generation stent delivery systems, in which the pressure tracings could be visualized more clearly. This could be due to the thinner shafts of these delivery systems. Standard procedures were followed during the angioplasty. During the procedure, a second wire could be taken through the diagnostic catheter if required and parked in the coronaries. However, in none of the cases was bifurcation stenting performed. During the angioplasty, opacification of the coronaries was less than with guide catheters, but even so the coronaries and the lesion location were clearly visualized. Immediately after stent placement, the coronaries were visualized by contrast injection, and the stent was visualized clearly. The stent could be easily and safely taken inside the diagnostic catheter and then to the lesion. In an emergency setting, complex interventional cases can also be tackled with this technique, as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Thrombus aspiration was not performed in any of the cases. Peri-procedural complications or noreflow phenomenon was not seen in any of the cases and none of these 34 patients suffered reinfarction in a one-month follow-up. One patient had a coronary artery dissection at the distal edge of the stent, which was stented. No dissection was observed at the site of coronary ostial engagement. There were no deaths, and contrast-induced nephropathy (32% increase in creatinine from baseline) was seen in only one patient, in whom creatinine levels improved over the following few days.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Pushability and trackability</span><p id="par0055" class="elsevierStylePara elsevierViewall">The trackability tests measured the force required to advance the catheters along a tortuous femoral path. The displacement forces required to advance the catheter were measured. Pushability was measured as the ratio of distal to proximal forces. Results of the pushability and trackability tests are given in <a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The force transmission parameters are shown in Supplementary Tables 1 and 2. The diagnostic catheters require more force (mean 7.83±1.57 vs. 4.06±2.29 N). However, the ratio between proximal and distal forces was 0.28 for diagnostic catheters, and for guide catheters it was 0.51. The diagnostic catheters have more maneuverability, as reflected by the maximal force parameters (10.03 vs. 7.73 N), but the guide catheters have high force transmission ratios.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8–12</span></a> To ensure successful procedures in real time, better maneuverability parameters enable easier engagement of catheters in the coronary ostium.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8–12</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Distal tip flexion test</span><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a> summarizes the results of distal tip flexion testing on five catheters. The distal tip flexion of the diagnostic catheters show balanced force displacement curves. The area inside the curve shows the hysteresis between elasticity and plasticity. The 5F XBU shows large displacement with small forces, whereas the 6F JL and 6F JR guide catheters show less displacement with large forces. The slope of the curve represents the stiffness of the catheters. The diagnostic catheters show optimal stiffness; the guide catheters have more stiffness and the 5F XBU catheter is less stiff.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8–12</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Three-point bending tests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The three-point bending tests were performed at 4.5 cm and 10 cm from the distal tip of the catheters. The force displacement curves of the catheters are shown in <a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>A and B. The diagnostic catheters have a balanced force displacement compared to the guide catheters, with less plastic deformation as shown by a smaller area inside the curves.</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Intravascular ultrasound catheter in diagnostic catheters</span><p id="par0075" class="elsevierStylePara elsevierViewall">The IVUS catheter (OptiCross 3.1 F) could be taken inside the 6F JR and JL diagnostic catheters and could be exteriorized through the distal tip of the catheters with ease, as observed in bench testing.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Advantages of diagnostic catheters in angioplasty</span><p id="par0080" class="elsevierStylePara elsevierViewall">It is feasible to perform angioplasty and stenting using 6F Cordis<span class="elsevierStyleSup">®</span> diagnostic catheters as an emergency procedure in ACS. This technique could be used as a bailout procedure, although it is not advisable for routine use. Difficulty in engagement often subjects the operator to psychological stress, especially when patients have ongoing angina or MI. The major advantage of this technique is that it minimizes procedural time as well as contrast use.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Frequent exchanges of catheters are often associated with increased procedural and fluoroscopy times and thus with procedural complications,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> increased contrast use,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14,15</span></a> infections or bacteremia,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> and thrombotic complications.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> As a bailout procedure, this technique is useful and feasible in ACS, when difficulty in engagement is encountered with guide catheters. The contrast load is reduced, in contrast to the larger contrast quantity commonly required in such situations. Also, in life-threatening situations in which a perfect result is not a major concern and time is of the essence, this method can be very useful.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6,7</span></a> In our study, in more than 50% of cases the contrast load used was less than 50 ml including the diagnostic angiogram. Maximum contrast use was 110 ml in one patient, and the mean was 45 ml.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">GuideLiner and deflectable tip catheters</span><p id="par0090" class="elsevierStylePara elsevierViewall">GuideLiner, deflectable tip or steerable catheters are some of the other options available in the present scenario for difficult cannulation.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17,18</span></a> However, these techniques are expensive and time-consuming, and are not available in all catheterization centers.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Measurement of coronary pressures</span><p id="par0095" class="elsevierStylePara elsevierViewall">The other difficulty is the assessment of pressures, which are damped to a certain extent; this would be a limitation on the use of diagnostic catheters as a routine technique. Although pressures are slightly damped, the pressure tracings are visible, and it is feasible to perform the procedure. As an observation, the pressure tracings were better visualized with newer-generation stent delivery systems.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Catheters and site</span><p id="par0100" class="elsevierStylePara elsevierViewall">It is also important to mention that all these procedures were performed with Cordis<span class="elsevierStyleSup">®</span> diagnostic catheters only. There are no other comparative studies on the use of other diagnostic catheters for this purpose. It was the operator's choice to use these catheters. It is worthwhile noting that in 10 out of 34 cases the procedures were performed for right coronary artery lesions, in which difficulty in engaging guide catheters is more frequent.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Trackability and pushability</span><p id="par0105" class="elsevierStylePara elsevierViewall">In bench testing the trackability characteristics were better for diagnostic catheters than for guide catheters. Also, the diagnostic catheters sustained more proximal force, and the distance at maximal force was more than 53 cm in the 54 cm tortuous path defined in the study protocol (mean 53.3±0.25 cm). The mean distance for the guide catheters was 49.6±4.17 cm.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The diagnostic catheters have better pushability characteristics. The diagnostic catheters sustained more proximal force and had better distal force transmission compared to guide catheters as reflected by the ratio of proximal and distal force. Also, the guide catheters cannot sustain as much proximal force as diagnostic catheters, which is often required in tortuous or calcific iliac arteries and aortas.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Three-point bending and distal tip flexion tests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The comparisons of three-point bending tests (<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>A and B) show that the area under the curves, which indicates the work performed or the kinetic energy stored in the catheters during catheter deformation, is higher for diagnostic catheters than for guide catheters. Also, the area inside the curves is less for the diagnostic catheters, which indicates less plastic deformation. The slope of the force-distance curve indicates the acceleration of the movement, which is also greater than in guide catheters.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The distal tip flexion tests show good characteristics in the diagnostic catheters compared to guide catheters. The 3.5 JR demonstrates large plastic deformation, while the 3.5 JL and 3.0 XBU show less elastic properties.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Intravascular ultrasound and optical coherence tomography catheters</span><p id="par0125" class="elsevierStylePara elsevierViewall">Currently available IVUS and optical coherence tomography (OCT) catheters are about 3F or less with hydrophilic coating, and they are 5F guide compatible. Hence, these imaging catheters can also be safely used in these diagnostic catheters. Bench evaluation of the OptiCross IVUS catheter demonstrated that it could easily go through the 6F JR and JL diagnostic catheters. The OptiCross catheter's shaft is 3.1F (1 mm), and hence this is feasible. The Dragonfly™ OCT catheter (St. Jude Medical) has a shaft diameter of 2.7 F. This is comparable to the shaft diameters of stents like Endeavor (2.8F), Onyx (2.7F), Nobori (2.5F) and Yukon Choice (2.6F). Since all these stents can pass through 6F Cordis<span class="elsevierStyleSup">®</span> diagnostic catheters, OCT and IVUS are feasible for use in these diagnostic catheters.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Contrast-induced nephropathy</span><p id="par0130" class="elsevierStylePara elsevierViewall">Emergency angioplasties are associated with a high incidence (15-20%) of contrast-induced nephropathy. In our series contrast-induced nephropathy was seen in only one patient, in whom creatinine increased from 1.3 mg/dl to 1.8 mg/dl, and after a few days decreased to 1.2 mg/dl. Contrast volume is a major determinant of contrast-induced nephropathy.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">19–21</span></a> In this series, the mean contrast volume was only about 45 ml, and no mortality was observed. However, the total number of cases was less.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">Using this method bifurcation lesion therapy and thrombosis aspiration<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> before stenting cannot be performed. In our center, it is the operator's choice that thrombosis aspiration is not performed routinely in all acute emergencies, but only in cases with a very high clot burden. The routine treatment of choice in ACS is direct stenting. Predilatation and stenting are used when direct stenting is not feasible. There are increasing reports of the benefits of direct stenting.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">23,24</span></a> In bifurcation lesions in an emergency setting, provisional stenting is the preferred method. Bifurcation lesion therapy and thrombosis aspiration may not always be required in routine emergency procedures. Also, in this study a switch to a radial approach was not tried when the femoral route failed, which is another available option. This is due to the operator's choice of the femoral route in ACS. However, the diagnostic catheter technique is an easy method for the majority of lesions in an emergency setting. Simplicity of the procedure is also a common priority in most cases of ACS, in which time and contrast load are major concerns, especially in patients with ongoing angina or MI.</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conclusion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Angioplasty can be performed successfully and safely using 6F Cordis<span class="elsevierStyleSup">®</span> INFINITI diagnostic catheters, which is a useful alternative when guide catheters fail to engage during angioplasty.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1005647" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec965436" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1005648" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec965435" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Engagement of diagnostic catheters" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Lesion characteristics" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Stent and balloon characteristics" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Catheter testing" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Intravascular ultrasound catheter evaluation" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Procedure" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Pushability and trackability" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Distal tip flexion test" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Three-point bending tests" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Intravascular ultrasound catheter in diagnostic catheters" ] ] ] 7 => array:3 [ "identificador" => "sec0070" "titulo" => "Discussion" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Advantages of diagnostic catheters in angioplasty" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "GuideLiner and deflectable tip catheters" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Measurement of coronary pressures" ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "Catheters and site" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "Trackability and pushability" ] 5 => array:2 [ "identificador" => "sec0100" "titulo" => "Three-point bending and distal tip flexion tests" ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Intravascular ultrasound and optical coherence tomography catheters" ] 7 => array:2 [ "identificador" => "sec0110" "titulo" => "Contrast-induced nephropathy" ] 8 => array:2 [ "identificador" => "sec0115" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0120" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack339179" "titulo" => "Acknowledgment" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-06" "fechaAceptado" => "2017-04-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec965436" "palabras" => array:6 [ 0 => "Emergency angioplasty" 1 => "Difficulty in engagement" 2 => "Diagnostic catheters" 3 => "Distal tip flexion" 4 => "Three-point bending tests" 5 => "Pushability and trackability" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec965435" "palabras" => array:6 [ 0 => "Angioplastia de emergência" 1 => "Dificuldade de progressão" 2 => "Cateteres de diagnóstico" 3 => "Flexão distal da ponta" 4 => "Testes de curvatura em três pontos" 5 => "Suporte e traceabilidade" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Difficulty in engaging with guide catheters is not uncommon in acute emergencies. We aimed to evaluate the use of Cordis<span class="elsevierStyleSup">®</span> INFINITI diagnostic catheters to perform angioplasty in patients in whom the coronaries cannot be engaged using standard guide catheters.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In 34 cases of acute coronary syndrome, when difficulty in engagement with two standard guide catheters was encountered with reasonable manipulations, angioplasty was performed using diagnostic catheters. In total, 40 stents were placed by this technique. Pushability and trackability, distal tip flexion and three-point bending tests were performed to evaluate the performance of the guide and diagnostic catheters.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Angioplasty was performed easily in a setting where it would have been very difficult to perform. Coronary dissection occurred in one patient, treated by a stent. The stent and dilatation balloons were easily passed through the diagnostic catheters. Pressure tracings were clearly preserved with certain stent delivery systems, and at angioplasty, although there was slightly reduced opacification of the respective artery, the coronary anatomy was sufficiently visualized to perform angioplasty. No periprocedural target lesion complications were seen in any cases.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pushability and trackability tests showed good force transmission along a tortuous path with diagnostic catheters, and balanced force-displacement curves from three-point bending tests and distal tip softness tests.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Angioplasty with stenting can be performed safely through 6F Cordis<span class="elsevierStyleSup">®</span> infiniti diagnostic catheters when difficulty in engaging guide catheters is encountered.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução e objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Avaliar o papel dos cateteres diagnósticos para efetuar angioplastia em doentes em que se verifica incapacidade de entubar seletivamente as artérias coronárias com os cateteres-guia padrão.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A entubação difícil pelos cateteres-guia não é rara no contexto de emergência. Em 34 casos de síndromes coronárias agudos, quando se encontrou dificuldade na entubacão com dois cateteres-guia padrão através das manipulacões habituais, a angioplastia foi realizada com cateteres diagnósticos. No total, 40 stents foram implantados com essa técnica. O suporte e a traceabilidade, a flexão da ponta distal e de três pontos da curva foram usados para avaliar o comportamento dos cateteres-guia e de diagnóstico.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A angioplastia foi efetuada facilmente num contexto em que era aparentemente muito difícil de fazer. Observou-se disseção coronária num caso, tratada com um <span class="elsevierStyleItalic">stent</span>. Os <span class="elsevierStyleItalic">stents</span>, tais como as dilatações por balão, foram facilmente implantados através de cateteres de diagnóstico. As curvas de pressão mantiveram-se claramente preservadas com alguns sistemas de entrega de <span class="elsevierStyleItalic">stents</span> e na angioplastia verificou-se uma ligeira redução da opacificação da artéria. Contudo, a anatomia coronária foi efetivamente visualizada para efetuar a angioplastia. Não se observou qualquer complicação nas lesões-alvo em qualquer dos casos intervencionados. Os testes de apoio e a traceabilidade revelaram uma força de transmissão através de trajetos tortuosos com cateteres de diagnóstico com curvas equilibradas da força-deslocação nos três pontos da curva em teste e na agressividade da ponta distal.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">As angioplastias com <span class="elsevierStyleItalic">stent</span> puderam ser feitas com segurança através de cateteres de diagnóstico (Cordis<span class="elsevierStyleSup">®</span> infiniti) quando se verificou uma dificuldade na entubação pelos cateteres-guia.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0135" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3962 "Ancho" => 2083 "Tamanyo" => 523470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Angiograms of angioplasties and stenting performed using diagnostic catheters: angioplasty in the proximal left anterior descending (LAD) artery (A and B); angioplasty in the mid right coronary artery with clots (C and D); angioplasty of the proximal LAD in a patient in cardiogenic shock (E and F), and angioplasty of the proximal LAD in a critically ill patient (G and H).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2995 "Ancho" => 3169 "Tamanyo" => 1035878 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Lists of diagnostic and guide catheters and their identification names used in the study. I.D.: inner diameter.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3259 "Ancho" => 2083 "Tamanyo" => 401423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Complicated stenting of right coronary artery performed with diagnostic catheters. The proximal right coronary artery (RCA) was 100% occluded (A), and the lesion was crossed with a BMW wire with balloon support, and balloon dilatation was performed (B). A dissection was observed in the mid RCA (C), and stenting was performed from proximal to mid RCA (D and E).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1897 "Ancho" => 1566 "Tamanyo" => 152865 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Results of pushability and force transmission measurements of the catheters. DC: diagnostic catheters; GC: guide catheters.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1976 "Ancho" => 1590 "Tamanyo" => 199232 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Results of trackability measurement of the catheters by force-distance curves. DC: diagnostic catheters; GC: guide catheters.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1378 "Ancho" => 1583 "Tamanyo" => 161913 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Results of distal tip flexion tests and maximum force distance table. DC: diagnostic catheter; GC: guide catheter.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 2710 "Ancho" => 1590 "Tamanyo" => 328746 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Results of three-point bending test measured at 4.5 and 10 cm from the distal tip with maximum force distance parameters. DC: diagnostic catheter; GC: guide catheter.</p>" ] ] 7 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 17410 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.P. Cannon" 1 => "C.M. Gibson" 2 => "C.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 7 | 16 |
| 2024 October | 49 | 25 | 74 |
| 2024 September | 59 | 21 | 80 |
| 2024 August | 52 | 38 | 90 |
| 2024 July | 30 | 37 | 67 |
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| 2024 May | 37 | 25 | 62 |
| 2024 April | 46 | 38 | 84 |
| 2024 March | 43 | 29 | 72 |
| 2024 February | 35 | 47 | 82 |
| 2024 January | 38 | 35 | 73 |
| 2023 December | 38 | 23 | 61 |
| 2023 November | 48 | 19 | 67 |
| 2023 October | 31 | 18 | 49 |
| 2023 September | 32 | 23 | 55 |
| 2023 August | 54 | 20 | 74 |
| 2023 July | 45 | 9 | 54 |
| 2023 June | 58 | 13 | 71 |
| 2023 May | 88 | 21 | 109 |
| 2023 April | 49 | 4 | 53 |
| 2023 March | 81 | 19 | 100 |
| 2023 February | 62 | 17 | 79 |
| 2023 January | 44 | 16 | 60 |
| 2022 December | 72 | 20 | 92 |
| 2022 November | 64 | 24 | 88 |
| 2022 October | 70 | 16 | 86 |
| 2022 September | 60 | 37 | 97 |
| 2022 August | 47 | 33 | 80 |
| 2022 July | 48 | 35 | 83 |
| 2022 June | 51 | 17 | 68 |
| 2022 May | 58 | 32 | 90 |
| 2022 April | 63 | 30 | 93 |
| 2022 March | 49 | 36 | 85 |
| 2022 February | 51 | 32 | 83 |
| 2022 January | 57 | 21 | 78 |
| 2021 December | 43 | 30 | 73 |
| 2021 November | 58 | 42 | 100 |
| 2021 October | 62 | 42 | 104 |
| 2021 September | 59 | 27 | 86 |
| 2021 August | 79 | 42 | 121 |
| 2021 July | 70 | 31 | 101 |
| 2021 June | 58 | 26 | 84 |
| 2021 May | 53 | 38 | 91 |
| 2021 April | 61 | 81 | 142 |
| 2021 March | 70 | 20 | 90 |
| 2021 February | 98 | 18 | 116 |
| 2021 January | 54 | 19 | 73 |
| 2020 December | 49 | 12 | 61 |
| 2020 November | 57 | 30 | 87 |
| 2020 October | 106 | 21 | 127 |
| 2020 September | 76 | 28 | 104 |
| 2020 August | 41 | 13 | 54 |
| 2020 July | 82 | 12 | 94 |
| 2020 June | 75 | 20 | 95 |
| 2020 May | 100 | 18 | 118 |
| 2020 April | 71 | 13 | 84 |
| 2020 March | 96 | 23 | 119 |
| 2020 February | 206 | 32 | 238 |
| 2020 January | 50 | 16 | 66 |
| 2019 December | 64 | 8 | 72 |
| 2019 November | 45 | 9 | 54 |
| 2019 October | 77 | 9 | 86 |
| 2019 September | 121 | 12 | 133 |
| 2019 August | 59 | 9 | 68 |
| 2019 July | 67 | 7 | 74 |
| 2019 June | 68 | 30 | 98 |
| 2019 May | 80 | 15 | 95 |
| 2019 April | 119 | 27 | 146 |
| 2019 March | 187 | 20 | 207 |
| 2019 February | 94 | 12 | 106 |
| 2019 January | 122 | 25 | 147 |
| 2018 December | 110 | 23 | 133 |
| 2018 November | 102 | 15 | 117 |
| 2018 October | 126 | 31 | 157 |
| 2018 September | 32 | 13 | 45 |
| 2018 August | 41 | 7 | 48 |
| 2018 July | 32 | 5 | 37 |
| 2018 June | 35 | 6 | 41 |
| 2018 May | 26 | 7 | 33 |
| 2018 April | 79 | 18 | 97 |
| 2018 March | 47 | 11 | 58 |
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