CASE REPORT Print ISSN 1738-5520 / On-line ISSN 1738-5555

Korean Circ J 2008;38:287-290 Copyright ⓒ 2008 The Korean Society of Cardiology

Angioplasty for Difficult Complex Lesions

With Using the VentureTM Catheter for Wire Placement
Tae Kun Lee, MD1, Sang Kwon Lee, MD2, June Hong Kim, MD1, Jae-Hoon Choi, MD1, Jun Kim, MD1,
Han Cheol Lee, MD1, Kook Jin Chun, MD1, Taek Jong Hong, MD1 and Yung Woo Shin, MD1
1
Departments of Internal Medicine and 2Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Busan, Korea

ABSTRACT

We report here on the use of the VentureTM catheter to facilitate successful advancement of a guidewire across
difficult, complex lesions after the prior attempts at guide wire passage were unsuccessful with using standard wires.
This VentureTM catheter may increase the success rate and reduce the procedural time for such a challenging in-
terventional procedure. ( Korean Circ J 2008;38:287-290)
KEY WORDS: Angioplasty; Catheter.

Introduction III angina. Coronary angiography showed 60 percent

Significant angulation and subtotal occlusion are
predictive for procedural failure during percutaneous
coronary intervention.1-3) A proximal stenosis of the
circumflex artery, when combined with severe angulation
or no visible stump can confer a higher chance of guid-
ewire failure despite the use of modern highly steerable
guidewires.
The Venture Catheter (St. Jude Medical Inc., Minn-
eapolis, MN, USA) is the only deflectable catheter for
guidewire delivery in this challenging anatomy. This
catheter is a low-profile, 6 Fr-compatible, torqueable,
support catheter with an 8 mm deflectable atraumatic
radiopaque distal tip and it provides support for sub-
sequent wire passage. We present here two cases that
demonstrate the benefit of this recently available ca-
theter with a deflecting tip to help negotiate subtotal
occlusion or severely angled take-offs of the left circum-
flex artery from the left main coronary artery.
Case
Case 1
A 61-year old female with a history of hypertension
presented with Canadian Cardiovascular Society Class
Received: December 27, 2007
Revision Received: January 22, 2008
Accepted: February 13, 2008
Correspondence: June Hong Kim, MD, Department of Internal Medicine, Pu-
san National University School of Medicine, Ami-dong, Seo-gu, Busan
602-739, Korea
Tel: 82-51-240-7795, Fax: 82-51-240-7796
E-mail: aangell@hananet.net
tubular eccentric luminal narrowing at the left anterior
descending artery (LAD) ostium and subtotal occlusion
at the left circumflex artery (LCx) ostium. Angiogram
showed no visible stump to pass the guidewire across
the lesion (Fig. 1A).
Using the right femoral approach, an 8 French Extra
back-up guiding catheter was engaged in the left main
coronary artery. Initial attempts to cross the left circum-
flex artery ostium were made with hydrophilic-coated
0.014" guidewires such as the BMW (Guidant Corp.,
Santa Clara, CA, USA) and the Choice PT2 (Boston
Scientific., Natick, MA, USA). However, these attempts
were unsuccessful due to the lack of back-up support and
the unsuitable angulation. The VentureTM Wire Control
Catheter was then advanced over the guidewire. The
distal tip of the Venture Catheter was directed toward
the LCx ostial lesion and the tip was deflected to point
towards the origin of the occlusion (Fig. 1B). A 0.014"
hydrophilic guidewire was advanced through the Ven-
ture Catheter tip. This catheter tip provided back-up
support for the guidewire as it was directed around the
angle and across the occlusion. The guidewire was then
continually advanced to the distal LCx (Fig. 1C).
After removal of the Venture Catheter, the lesion was
pre-dilated with an undersized balloon (2.0×20 mm),
and a Taxus stent (2.5×28 mm) was then implanted.
A Taxus stent (4.5×24 mm) was next deployed from
the left main coronary artery to the proximal LAD by
using the crushing technique. Finally, kissing balloon-
ing was attempted (Fig. 1D). Following the stent de-
ployment, a good angiographic result was obtained with
complete recovery of the LCx, and thrombolysis in

287
288·Venture Catheter in Complex Lesion

A B C

D E
Fig. 1. Angiographic findings of first case. A: subtotal occlusion without a visible stump at the ostium of the circumflex artery and there is
tubular eccentric luminal narrowing at the ostium of the left anterior descending artery. B: the tip of the Venture Catheter was deflected
and engaged at the ostium of the circumflex artery. C: a guidewire is advanced into the distal vessel. D: kissing ballooning after crushing
at the bifurcation lesion. E: the final angiographic result following balloon dilation and placement of two drug-eluting stents.

A B
2
Fig. 2. IVUS findings of first case. A: post-procedural IVUS findings of the left main artery (minimal stent area: 10.2 mm ). B: post-
2
procedural IVUS findings of the circumflex artery ostium (minimal stent area: 4.7 mm ). IVUS: intravascular ultrasound.

myocardial infarction (TIMI) grade 3 flow was observed
(Fig. 1E). The post-procedural intravascular ultrasound
(IVUS) findings showed an acceptable result [the mi-
nimal stent area (MSA) of the main stent was 10.2 mm2,
and the MSA of the LCx ostium was 4.7 mm2] (Fig. 2).
Case 2
A 59-year-old man with hypertension and a history
of smoking presented with unstable angina. He was
previously admitted in another hospital and he was then
transferred to our cardiovascular center for percutaneous
coronary intervention because of the presence of a di-
fficult complex lesion. Diagnostic coronary angiography
showed diffuse long eccentric luminal narrowing at the
LAD (Fig. 3A) and a severely angulated proximal LCx
with subtotal occlusion (Fig. 3B). Although there was a
small remaining stump of the proximal circumflex, it
was angulated at its origin. Despite multiple attempts,
 Tae Kun Lee, et al.·289

A B C D

E F G
Fig. 3. Angiographic findings of second case. A: initial coronary angiography showed the diffusely diseased lumen of the left anterior
descending artery. B: a severely angulated and subocclusive lesion at the ostium of the circumflex artery. C: an unsuccessful attempt to
pass a guidewire in the ostium of the circumflex artery by using a microcatheter. This was successfully advanced into the proximal
lesion, but it was unable to cross the second angle of the lesion. D: the Venture Catheter in a curved configuration engaging the circumflex
stump and the guidewire was advanced into the distal vessel. E: kissing ballooning after crushing at the bifurcation lesion. F, G: final results.

A B C
2
Fig. 4. IVUS findings of second case. A: pre-procedural IVUS findings of the distal left main artery (the cross sectional area is 8.9 mm
and there is a 61% plaque burden). B: pre-procedural IVUS findings of the left anterior descending artery ostium (the cross sectional
2
area is 5.5 mm and there is a 64% plaque burden). C: post-procedural IVUS findings of the circumflex artery ostium (minimal stent
2
area: 5.1 mm ). IVUS: intravascular ultrasound.

the wire repeatedly prolapsed distal into the LAD. So,
a microcatheter was positioned in the ostium of the
LCx. This was successfully advanced into the proximal
lesion, but it was unable to cross the second angle of
the lesion (Fig. 3C). The distal end of the Venture Ca-
theter was advanced into the LAD just beyond the
circumflex origin over a BMW wire (Guidant Corp.,
Santa Clara, CA, USA) and it was placed into a curved
configuration by clockwise rotation of the screw me-
chanism on the proximal control handle and then it
was gently withdrawn until it engaged the origin of the
LCx. The guide wire was then successfully advanced
through the catheter into the distal LCx (Fig. 3D) and
the Venture Catheter was removed.
After successful wiring, the pre-procedural IVUS find-
ings showed significant stenosis of the left main coro-
nary artery and the LAD ostium (Fig. 4A and B).
Predilation was performed with an undersized balloon
at the proximal LCx, and a Cypher stent (2.5×24
mm) was deployed. A 3.5×28 mm Cypher stent was
placed from the left main coronary artery to the pro-
ximal LAD and it was crushed into the LCx stent. After
crushing, a Cypher stent (2.75×28 mm) was deployed
at the mid LAD. This was followed by kissing ballooning
at the bifurcation lesion (Fig. 3E). We obtained good
angiographic (Fig. 3F and G) and IVUS results (Fig.
4C) (the MSA of the LCx ostium was 5.1 mm2).
Discussion
We describe here two cases of using a Venture Catheter
to enable access to LCx ostial lesions where severe angu-
290·Venture Catheter in Complex Lesion
lation and total occlusion caused difficult wire support.
The Venture Catheter has previously been documented
for use in tortuous vessels, chronic total occlusion and
in cases of complex interventions that are beyond in-
serting the guide wire into coronary bypass grafts.4)5)
This device has been used to treat those renal artery
aneurysms that have difficult vasculature.6)
We used a “Grapple Hook” technique in the second
case. This technique means that the catheter was first
advanced in its straight configuration over a wire to a
location just beyond the target and only at that point
is it actively flexed and withdrawn to engage the target
vessel. Although there is the potential for causing trauma
to the vessel, the relatively large diameter of the proximal
LAD vessel permitted axial rotation and withdrawal of
the catheter with a curved configuration. This approach
was used in a previous report without complications.7)
Despite the improvement of the operator’s technique
and equipment for performing percutaneous coronary
intervention, this procedure can still fail in difficult
complex lesions. We demonstrated that this new device
was useful to facilitate wire passage in severely angulated
vessels and non visible stump lesions. So, this device
offers an additional option and it may improve the
procedure success of percutaneous revascularization in
those patients who have difficult vasculature.
REFERENCES
1) Ellis SG, Vandormael MG, Cowley MJ, et al. Coronary morpho-
logic and clinical determinants of procedural outcome with an-
gioplasty for multivessel coronary disease: implications for patient
selection. Circulation 1990;82:1193-202.
2) Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morpho-
logic determinants of coronary angioplasty success and compli-
cations: current experience. J Am Coll Cardiol 1995;25:855-65.
3) Yum JH, Jeong MH, Seoung KB, et al. Percutaneous coronary
intervention using crosswireNT in total occlusion of coronary
artery. Korean Circ J 2002;32:125-30.
4) Naidu SS, Wong SC. Novel intracoronary steerable support ca-
theter for complex coronary intervention. J Invasive Cardiol 2006;
18:80-1.
5) McClure SJ, Wahr DW, Webb JG. Venture wire control catheter.
Catheter Cardiovasc Interv 2005;66:346-50.
6) Aranzulla TC, Colombo A, Sangiorgi GM. Successful endovascular
renal artery aneurysm exclusion using the VentureTM Catheter
and covered stent implantation: a case report and review of the
literature. J Invasive Cardiol 2007;19:E246-53.
7) McNulty E, Cohen J, Chou T, Shunk K. A “grapple hook”
technique using deflectable tip catheter to facilitate complex proxi-
mal circumflex interventions. Catheter Cardiovasc Interv 2006;
67:46-8.