Cardiovascular Revascularization Medicine 12 (2011) 391–398

Case Report

Use of the venture catheter to shorten the door-to-balloon time in patientswith ST-Segment elevation acute myocardial infarction☆

Timothy Ball, Subhash Banerjee, Emmanouil S. Brilakis⁎

VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75216, USA

Received 8 April 2011; received in revised form 5 May 2011; accepted 12 May 2011

Abstract Achieving a door-to-balloon time b90 min may be challenging in patients with ST-segment elevation

Abbreviations: EFartery; MI, myocardiaSTEMI, ST-segment e

☆ Conflict of inspeaker honoraria froJohnson and researchCompany. Dr. BrilakTerumo; research suppMedtronic (spouse).

⁎ CorrespondingTexas Health Care SyCenter, 4500 S. Lanc1547; fax: +1 214 302

E-mail address: es

1553-8389/11/$ – seedoi:10.1016/j.carrev.2

acute myocardial infarction with difficult to wire coronary lesions. We report use of the Venture wirecontrol catheter to facilitate wiring in four patients with significant tortuosity proximal to athrombotic coronary occlusion, after conventional wiring attempts failed. Early use of the Venturecatheter may help shorten the door-to-balloon time in patients with challenging to wire lesions.Published by Elsevier Inc.

Keywords: Acute myocardial infarction; Percutaneous coronary intervention; Technique

Shortening the door-to-balloon time in patients withST-segment elevation acute myocardial infarction (STEMI)is critical for minimizing morbidity and mortality. Whileprompt STEMI recognition and activation of the catheter-ization laboratory is crucial, difficulty to wire the targetlesion may cause delay in reperfusion. We report fourSTEMI cases, in which use of the Venture wire controlcatheter (St. Jude, Minneapolis, MN, USA) facilitatedwiring of the culprit lesion and shortened the door-to-balloon time.

, ejection fraction; LAD, left anterior descendingl infarction; PCI, percutaneous coronary intervention;levation acute myocardial infarction.terest disclosures: Dr. Ball: none. Dr. Banerjee:m St. Jude Medical, Medtronic and Johnson &support from Boston Scientific and The Medicinesis: speaker honoraria from St Jude Medical andort from Abbott Vascular and Infraredx; salary from

author. Division of Cardiology (111A), VA Northstem, The University of Texas Southwestern Medicalaster Rd, Dallas, TX 75216, USA. Tel.: +1 214 8571341.brilakis@yahoo.com (E.S. Brilakis).

front matter. Published by Elsevier Inc.011.05.001

1. Case 1

A 57-year-old man presented with posterior myocardialinfarction (Fig. 1A). Emergency coronary angiographyperformed with a 6-French 3.5 XB guiding catheterdemonstrated thrombotic occlusion of the proximalcircumflex artery (Fig. 1B). Wiring the proximal circum-flex was challenging due to severe proximal angulationcausing the wire to prolapse into the left anteriordescending artery (LAD) (Fig. 1C). We were unable toadvance an Asahi soft (Abbott Vascular, Santa Clara, CA,USA) or a Runthrough wire (Terumo, Somerset, NJ, USA)wire though the lesion, in spite of advancing them throughan over-the-wire balloon (wiring attempt time was 6 min).A Venture catheter (St. Jude) was subsequently positionedproximal to the lesion, and the tip was flexed to pointtoward the occlusion. A Runthrough wire (Terumo) wasthen advanced through the Venture catheter and, in spiteof forming a distal loop, successfully crossed the lesioninto the mid circumflex (Fig. 1D), which had heavythrombus burden and marked tortuosity (Fig. 1E). Thecrossing time with the Venture catheter (St. Jude) was 2min. The lesion was predilated with a 2.0-mm balloonwith improvement of antegrade flow. We were unable toadvance a rheolytic thrombectomy catheter, in spite of

Fig. 1. Electrocardiogram showing posterior myocardial infarction (panel A). Coronary angiography revealed occlusion of the proximal left circumflex artery (arrow, panel B). We were unable to advance a wirethrough the circumflex lesion due to wire prolapsed into the LAD (panel C). Using a Venture catheter (arrow, panel D), a Runthrough wire (Terumo) was advanced through the lesion (arrowhead, panel D). Afterpredilatation, large thrombus burden was seen in the proximal circumflex (arrow, panel E). After mechanical thrombectomy and stent implantation, TIMI 3 flow was restored (panel F).

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Fig. 2. Electrocardiogram showing anterior infarct (panel A). Diagnostic angiography demonstrating ostial occlusion of the LAD (arrow, panel B). A Venture catheter (arrow, panel C) was used to the wire the LAD.After stent implantation, TIMI 2 flow was restored (panel D).

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Fig. 3. Electrocardiogram showing anterior STEMI (panel A). Coronary angiography demonstrated occlusion of the LAD (panel B). Using a Venture catheter (St. Jude), the LAD was successfully wired (panel C),and flow was restored after stent implantation (panel D).

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Fig. 4. Electrocardiogram showing posterior STEMI (panel A). Coronary angiography revealed proximal occlusion of an anomalous circumflex arising om the proximal right coronary artery (panel B). Theanomalous circumflex was wired using a Venture catheter (St. Jude) (panel C), and after stent implantation, TIMI 3 flow was restored (panel D).

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using a buddy wire (Ironman; Abbott Vascular), but wereable to advance a 6-French mechanical aspiration catheter(Fetch; Possis Medical, Minneapolis, MN, USA) toaspirate a large amount of thrombus. The lesion wassuccessfully stented with three overlapping sirolimus-eluting stents (Cypher; Cordis, Warren, NJ, USA), with anexcellent final angiographic result and Thrombolysis InMyocardial Infarction (TIMI) 3 flow (Fig. 1F). The patienthad an uneventful recovery and remained asymptomaticduring 2-years of follow-up.

2. Case 2

A 64-year-old man with diabetes, hypertension, atrialfibrillation and prior stroke presented with anterior STEMI(Fig. 2A). Diagnostic angiography demonstrated ostialocclusion of the LAD (Fig. 2B). We were unable to wirethe LAD in spite of using an Asahi soft and a Pilot 200 wire(Abbott Vascular), because the wires entered the circumflexartery (attempt time, 4 min). A rapid exchange Venturecatheter (St. Jude) was advanced in the proximal LAD andprovided additional support enabling lesion crossing with aRunthrough wire (Terumo) (Fig. 2C) within 1 min.Following balloon predilation, rheolytic thrombectomy andimplantation of a 3.0×15-mm everolimus-eluting stent(Xience V; Abbott Vascular), TIMI 2 antegrade flow wasachieved, suggestive of no reflow (Fig. 2D). Echocardiog-raphy, following percutaneous coronary intervention, dem-onstrated anterior wall akinesis and an ejection fraction of20%. The patient had a long hospitalization complicated bycardiogenic shock requiring intra-aortic balloon pump andinotropic support, respiratory failure requiring intubation andeventually tracheostomy, and recurrent infections.

Table 1Characteristics of the Venture catheter (St. Jude)

Specifications Rapid exchange Over-the-wire

Working length 145 cm 140 cmRapid exchange segment length 30 cm NARadiopaque tip length 8 mm 8 mmTip bend radius 2.5 mm 2.5 mmEntry profile 0.019″ 0.019″Proximal shaft profile 3.5F 3.5FGuide catheter compatibility 6F 6FGuidewire compatibility 0.014″ 0.014″

NA, not applicable.

3. Case 3

A 62-year-old man with diabetes and hypertensionpresented with anterior STEMI (Fig. 3A). Emergencycoronary angiography showed mid-LAD occlusion (Fig.3B). Multiple attempts to wire the mid-LAD lesion withmultiple wires failed (wiring attempt time was 6 min). Eachwire preferentially entered a septal perforator branchlocated immediately proximal to the occlusion (arrow,Fig. 3B). A Venture catheter (St. Jude) was advancedproximal to the lesion enabling successful crossing of thelesion (Fig. 3C) within 1 min. Predilatation was performedwith a 2.0-mm balloon, and mechanical thrombectomy wasperformed using a 7-French Export catheter (Medtronic,Santa Rosa, CA, USA). The mid-LAD was stented with a2.5-mm everolimus-eluting stent (Xience V; AbbottVascular), but no reflow occurred. After intracoronaryadministration of adenosine and nicardipine through theExport catheter, TIMI 2 flow was achieved (Fig. 3D).During the 18-month follow-up, he had no recurrentcardiac symptoms.

4. Case 4

A 65-year-old man with diabetes and hypertensionpresented with posterior STEMI (Fig. 4A). Coronaryangiography showed proximal occlusion of an anomalouscircumflex arising from the proximal right coronary artery(Fig. 4B). We were unable to wire the anomalouscircumflex due to severe proximal tortuosity in spite ofusing an Asahi soft, Pilot 200, Fielder XT (AbbottVascular) and a Runthrough wire (Terumo) (wiring attempttime 9 min). A Venture catheter (St. Jude) was advancedproximal to the lesion and directed a Whisper (AbbottVascular) guidewire through the circumflex lesion (wiringtime was 2 min, Fig. 4C). The lesion was predilated with a2.0-mm balloon, and mechanical thrombectomy wasperformed with a 7-French Xtract catheter (Volcano,Rancho Cordova, CA, USA). After implantation of a2.5×28-mm and a 2.75×23-mm everolimus-eluting stents(Xience V; Abbott Vascular), an excellent final angio-graphic result was achieved with TIMI 3 flow (Fig. 4D).The patient returned 1 month later with recurrent atypicalchest pain. On repeat angiography, the anomalous circum-flex stents were patent, but an additional stent was placed ina 70% mid-right coronary artery lesion. During 9 months offollow-up, he had no recurrent cardiac symptoms.

5. Discussion

We describe use of the Venture wire control catheter(St. Jude) for facilitating wiring of a STEMI culprit lesion.Use of the Venture result enabled fast lesion wiring,shortening the door-to-balloon time.

Several strategies have been proposed for wiringtortuous lesions, such as utilizing polymer jacket guide-wires or wire directing catheters [1]. The Venture catheter(St. Jude) is available as rapid exchange and over-the-wiresystem (Table 1, Fig. 5). It has an 8-mm radiopaque tipthat can be deflected up to 90° by rotating a proximal tipdeflection knob (Fig. 5). The entire catheter can be rotatedvia a more distal torque handle (Fig. 5). The Venturecatheter (St. Jude) also has a stiff body that providesadditional support during wire advancement attempts.

Fig. 5. Illustration of the rapid exchange and the over-the-wire Venture catheter (St. Jude). Reprinted with permission from St. Jude Medical, 2011 allrights reserved.

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These two attributes allow it to be effective in challengingto wire lesions. The Venture catheter has been shown to beeffective in wiring tortuous lesions [2-5], bifurcations[2,6], saphenous vein grafts [7], aneurysms [8] and chronictotal occlusions [2,9-11]. Our report extends the previousobservations, suggesting that early use of the Venturecatheter in patients with STEMI could facilitate lesionwiring and result in faster reperfusion. Crossing of thetarget lesions was unsuccessful in spite of wiring attemptslasting between 4 and 9 min, but was successful within 2min in all cases in our patients.

Two types of lesions are described in this series: (a)proximal circumflex and (b) LAD occlusion with a largediagonal branch proximal to the lesion. Wiring ofproximal circumflex lesions can be particularly challengingbecause the circumflex artery often arises at a 90° anglefrom the left main coronary artery, and attempts toadvance a wire may lead to wire prolapse in the LAD(Fig. 1C). The Venture catheter (St. Jude) can beparticularly helpful in such cases, both by preventingwire prolapse and by facilitating wire steering into thelesion, as reported by McNulty et al. [3] (2 cases, 100%success), Aranzulla et al. [5] (2 chronic total occlusions,50% success) and Iturbe et al. [9] (7 chronic totalocclusion cases, 100% success).

Presence of a large side branch proximal to an LADocclusion has been associated with chronic total occlusionpercutaneous coronary intervention failure [12]. We recentlydemonstrated that use of the Venture catheter (St. Jude) and astiff wire may enable wiring of such lesions [11]. Similarly,in cases 2 and 3 of the present series, use of the Venturecatheter prevented wire entry into the side branch andreinforced wire penetration through the lesion.

Use of the Venture catheter (St. Jude) in STEMI haslimitations. Deciding to use it and advancing it to the lesionrequires some (although limited) time. Manipulations of the

catheter within the vessel to point it to the lesion may causevessel injury. Using the Venture catheter (St. Jude)significantly enhances the wire penetrating force creating arisk for perforation that can be minimized by using soft-tipwires, or by wiring using a distal tip loop, as in case 1.

In summary, use of the Venture catheter in challengingSTEMI-causing lesions may facilitate lesion wiring andshorten the time to coronary reperfusion.

Acknowledgment

We gratefully acknowledge the tremendous support ofthe cardiac catheterization laboratory team at the DallasVA Medical Center for enabling the development ofnovel catheterization techniques and the performance ofclinical research.

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