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The Journal of Invasive Cardiology®
Case Report
E148
ABSTRACT: The difficult performance of certain percutaneous in-
terventions in the field of congenital heart disease is well known. Cross-
ing pulmonary arteries in patients who have previously undergone
surgical repair or stenotic pulmonary veins in infants can be typical ex-
amples of these technical challenges in the catheterization laboratory.
The Venture wire 6 Fr control catheter (St Jude Medical) is com-
patible with a steerable tapered radiopaque tip that can be manually an-
gulated (up to 90˚) by clockwise rotation of a knob located in the
proximal handle. This mechanism directs any 0.014"guidewire and
provides back-up support. This catheter has been successfully used in
coronary artery intervention for crossing severely tortuous vessels, ex-
treme angulations of side-branch ostia, jailed stents, saphenous vein
graft anastomoses, and chronic total occlusions.
We report the first use of the Venture wire control catheter (St Jude
Medical) in the field of congenital heart disease. Patient #1 was diag-
nosed with pulmonary atresia and ventricular septal defect and had a
proximally migrated stent in the pulmonary trunk and severe left pul-
monary artery stenosis. We have used this catheter in order to cross this
stent and perform left pulmonary artery stent placement. Patient #2
had postoperative vein restenosis after surgery. The Venture catheter
was used to reach the obstructed insertion of the right medium lobe
pulmonary vein from a transseptal approach.
Techniques from coronary interventional colleagues can help inter-
ventional cardiologists in the field of congenital heart disease to treat
complex situations.
J INVASIVE CARDIOL 2012;24(7):E148-E152
Key words: congenital heart defects, pulmonary atresia,
pulmonary artery, stents
It is not uncommon to use techniques or tools from coronary
artery intervention to treat lesions in other fields of percutaneous
intervention. The Venture wire control catheter (St Jude Med-
ical) is a 6 French (Fr) compatible, over the wire or monorail,
140 cm braided support catheter. The steerable tapered ra-
diopaque tip can be manually angulated (up to 90˚) by clockwise
rotation of a knob located in the proximal handle. This mecha-
nism directs any 0.014"guidewire and provides back-up sup-
port. This catheter has been used to cross severely tortuous ves-
sels, extreme angulations of side-branch ostia, jailed stents,
saphenous vein graft anastomoses, and chronic total occlusions.1-
7The first extra coronary use of this catheter was reported in
reaching a renal artery aneurysm.8It is well known that crossing
pulmonary arteries or veins in patients who have previously un-
dergone surgical repair of congenital heart defects can be tech-
nically challenging in the catheterization laboratory. To the best
of our knowledge, there is no report on the use of this catheter
for congenital heart defects in the published literature.
Case Reports
Patient 1. A 7-year-old boy with the diagnosis of pulmonary
atresia and ventricular septal defect, hypoplastic pulmonary arteries,
and major aortopulmonary collateral arteries (MAPCAs) was re-
ferred to our institution. The patient was previously palliated with
a 5 mm right modified Blalock-Taussig shunt at 3 years of age. Two
years later the patient underwent complete correction with patch
ventricular septal defect closure, placement of a 16 mm Carpentier-
Edwards bioprosthetic valved conduit (Edwards Lifesciences) from
the right ventricle to the pulmonary artery, patch enlargement of
the pulmonary arteries, and ascending aortoplasty. Cardiac catheter-
ization performed 15 days post-surgery showed a tight stenosis at the
origin of the left pulmonary artery (LPA) where a 17 mm JoStent
(Abbott) was implanted, mounted on a 8 mm x 20 mm Cristal bal-
loon (Balt), and MAPCAs from the descending aorta and right sub-
clavian artery. One of these was embolized with a 3 mm x 5 loop
coil. During follow-up CT scan, we noticed that the stent had dis-
lodged into the conduit and there was severe stenosis of the LPA.
After contact with our center, the boy was transferred for evalua-
tion.
After positioning an extra-stiff guidewire in the right pulmonary
artery (RPA), an 8 Fr Mullins sheath was advanced to the pul-
monary artery trunk. Multiple injections confirmed the transversely
positioned embolized stent in the pulmonary trunk and severe LPA
stenosis with a right ventricular systolic pressure corresponding to
70% systemic pressure (Figure 1). The intended procedure was to
reach the LPA through the previous implanted stent without passing
through the stent struts, allowing new stent implantation. The align-
ment of the LPA stenosis was parallel to the stent position and the
angle from it to the main pulmonary artery was almost 180˚.
We decided to use the Mullins sheath system at the proximal part
of the stent and leave an extrastiff guidewire in the LPA, even if it
From the 1Instituto de Cardiologia do Rio Grande do sul/Fundacao Univer-
itåria de Cardiologia (IC/FUC) Cardiologia Invasiva, Porto Alegre, Brazil and
2Department of Interventional Cardiology in Congenital Heart Defects, I.R.C.C.S
Policlinico San Donato, San Donato Milanese, Italy.
Disclosure: The authors have completed and returned the ICMJE Form for
Disclosure of Potential Conflicts of Interest. The authors report no conflicts of
interest regarding the content herein.
Manuscript submitted January 25, 2012 and accepted March 14, 2012.
Address for correspondence: Gianfranco Butera, MD, PhD, Pediatric Cardi-
ology and GUCH unit – Policlinico San Donato IRCCS, Via Morandi, 30 –
20097 - San Donato Milanese. Email: gianfra.but@lycos.com
The Use of a Wire Control Catheter to Treat Complex Pulmonary
Artery or Vein Anatomy
Joao Luiz L. Manica, MD, Luciane Piazza, MD, MSc, Gianfranco Butera, MD, PhD
For Personal Use.
Copyright HMP 2012
Vol. 23, No. 7, July 2012 E149
Wire Control Catheter in CHD
crossed the stent cells, to give better support for the catheters and
guidewires to be used (Figure 2A). Five and 6 Fr right and left Jud-
kins, Amplatz right, and internal mammary coronary artery
catheters (Cordis) were then tried inside the Mullins sheath, posi-
tioned just distal to the proximal part of the stent, and a variety of
standard guidewires (Terumo hydrophilic, 0.014" coronary
guidewires such as Hi-Torque BMW [Abbott], and Whisper extra-
support [Abbott]) were used but failed to reach the LPA without
passing through the stent cells.
Sometimes, when the guidewire and the catheter successfully
crossed the whole stent without passing through the stent cells, it be-
came very difficult to direct the tip of the catheter to the left side as
the system then faced towards the RPA (Figure 2B). Even with a
balloon occluding the origin of the RPA, it was impossible to reach
the LPA due to the extremely acute angle between the delivery system
and the vessel.
After numerous attempts to access the LPA and 100 minutes of
procedure time, a Venture wire control catheter was placed inside
the Mullins sheath (St Jude Medical). We tried to direct a 0.014"
coronary guidewire towards the left pulmonary artery. When it had
just passed through the distal part of the stent, the tip of the catheter
was directed to the LPA with a rotation of the knob in the proximal
handle of the catheter. This maneuver enabled the distal bed of the
LPA to be reached with the catheter and guidewire to give adequate
Figure 1. Injection through a Mullins sheath in a craniocaudal left anterior oblique projection showing the stent dislodged in the pulmonary trunk
and residual severe left pulmonary artery stenosis (A). Scheme simulating the acute angle to be reached (B).
Figure 2. Injection through the Mullins crossing the proximal part of the stent and extra-stiff guidewires in both pulmonary arteries (A). Attempt to
cross the stent and to position a guidewire in the left pulmonary artery without passing through the stent cells using a left Judkins coronary artery
catheter (B).
For Personal Use.
Copyright HMP 2012
The Journal of Invasive Cardiology®
MANICA, et al.
E150
support (Figure 3). Afterwards, the Venture catheter was exchanged
for a multipurpose 4 Fr catheter over the coronary wire. An extra-
stiff guidewire was then positioned in the LPA without passing
through the stent cells and predilation of the stenosis with a Cristal
Balloon 8 mm x 30 mm (Balt) performed using a kissing balloon
technique to facilitate the later advancement of a Mullins sheath
delivery and subsequent stent placement (Figure 4A). The procedure
after the choice of the Venture catheter took 20 minutes.
Stent implantation was performed with a JoStent 28 mm (Ab-
bott) mounted on an 8 mm x 30 mm Cristal balloon post-dilated
with a 14 mm x 40 mm FoxCross balloon (Abbott) with a good
hemodynamic and angiographic result and a final right ventricular
to systolic pressure/systemic pressure ratio of 0.5. Eventually, the pre-
vious stent rearranged a better orientation towards the LPA (Figures
4B and 4C).
Patient 2. A 10-month-old infant was referred to our hospital
with the diagnosis of bilateral pulmonary veins restenosis after sur-
gical procedure with sutureless technique in the right-sided ostium
and patch angioplasty on the left-sided ostium. During the surgical
procedure, the surgeon left a small atrial septal defect. The patient
presented clinically unstable with signs of supra-systemic pulmonary
artery pressures at echocardiography and was referred for an attempt
of percutaneous balloon dilatation of the pulmonary veins. At car-
diac catheterization, right ventricular pressure was 120% of the sys-
temic pressure. Selective angiography at the ostium of the right upper
pulmonary veins clearly demonstrated stenosis that was dilated with
3 mm x 20 mm and 3.5 mm x 20 mm Hiryu balloon (Terumo)
and post-dilated with 5 mm x 20 mm Quantum Maverick balloon
(Boston Scientific) (Figure 5A). However, it was very difficult to
cannulate the insertion of the medium and inferior lobe drainage
due to an extreme angulation. After various attempts with usual
catheters and guidewires, we used the Venture catheter to inject con-
trast and confirm the stenosis and then to cannulate with a 0.014"
support guidewire. We then performed successful balloon dilatation
with 3.5 mm x 20 mm Hiryu balloon (Terumo) and post-dilation
with 5 mm x 20 mm Quantum Maverick balloon (Boston Scien-
tific) (Figures 5B-5D). Using a 5 mm x 20 mm Quantum Mav-
erick balloon, we performed dilatation of the obstructed ostium of
the left-sided pulmonary veins. Procedure was uneventful and pres-
sure in the right ventricle decreased to 60% of the systemic pressure.
The patient was discharged 10 days later clinically well and with
a stable result.
Discussion. Branch pulmonary artery stenosis is not an un-
common problem following complete repair of pulmonary atre-
sia and ventricular septal defects. It can be iatrogenic, induced
by a previous systemic to pulmonary shunt operation, or even
due to congenital hypoplastic pulmonary arteries. Clinically
these patients can be asymptomatic even with right ventricular
hypertension or can present with exercise intolerance. Right ven-
tricular dysfunction, arrhythmias, and sudden death are avoid-
able complications by treatment with stents.
Surgical access to distal pulmonary arteries, particularly in
patients previously operated on that have tissue adhesions, is
technically difficult and the incidence of restenosis and necessity
for another intervention is not inconsiderable. The excellent
long-term follow-up results of percutaneous pulmonary artery
stent implantation recently published in the literature make this
technique the standard of care for the management of branch
pulmonary artery stenosis.9
However this procedure is usually not straightforward and
can be extremely challenging for the interventionist due to in-
dividual patient anatomical differences. Difficulty in accessing
the left pulmonary artery, mainly when dealing with postoper-
ative patients, is already reported in the literature and is probably
Figure 3. Attempt to cross the stent and to position a guidewire in the left pulmonary artery with the Venture catheter (A). Scheme simulating the
angulated tip of the catheter and the guidewire in the left pulmonary artery (B).
For Personal Use.
Copyright HMP 2012
Vol. 23, No. 7, July 2012 E151
due to the S-shaped curve required to negotiate the curves from
inferior vena cava through the right ventricle and into the LPA.10
Moreover the necessity of reintervention is not uncommon, es-
pecially when dealing with children requiring pulmonary artery
redilation to accommodate future somatic growth.11 Sometimes
re-accessing the pulmonary arteries can be challenging and stents
previously implanted in the pulmonary outflow tract or at the
bifurcation can make it particularly difficult.
In the last decade, improvements in the whole percutaneous
interventional field have allowed the possibility of treating some
lesions in pulmonary arteries previously not possible for the in-
terventional cardiologist. New balloons and stent designs with
lower friendlier profiles, specifically designed for congenital heart
defects, have contributed to the widening application of percu-
taneous therapy to the pulmonary arteries. Moreover, innovative
applications of new technologies such as guidewires, catheters,
and techniques developed to cross-obstruct bifurcations in the
coronary arteries have also shown success in challenging cases in
the pulmonary arterial tree.
Congenital pulmonary vein stenosis is a rare but life-threat-
ening disease with the development of progressive pulmonary
venous congestion followed by pulmonary arterial hypertension
and eventual death. Surgical results, as well as percutaneous op-
tions are not encouraging with high mortality rate in infants,
but better results can be achieved in patients after the first year
of life and those with unilateral commitment.12-14 Despite acute
acceptable results, balloon dilation or stent implantation demon-
strate a high incidence of restenosis due to vessel recoil or neoin-
timal proliferation, respectively. More recently, cutting balloon
angioplasty was performed but was unable to halt the progressive
nature of this disease.15 In spite of the use of drug-eluting devices
to stop the neointimal proliferation from occurring, there is still
a lack of evidence to think it will be effective to treat this lethal
disease.16
The venous transseptal approach is always required in per-
cutaneous intervention in those patients. Usually, the angle to
access the right pulmonary veins is acute. Multiple attempts
are usually necessary to perform pulmonary vein cannulation
and in this kind of labile patient with severe pulmonary arterial
hypertension, the excessive catheter manipulation and contrast
media utilization can be fatal. Initial experience with the Venture
wire control catheter (St. Jude Medical) in the coronary arteries
demonstrated its utility in crossing severely tortuous or calcified
vessels, extremely angulated side-branch ostia, jailed stents, and
lesions distal to saphenous vein graft anastomoses.1-3 The use of
this technique to cross chronic total occlusions was first de-
scribed by Aranzulla et al4and then further success was described
in more recent reports.5-7 Until now there have been only 2 de-
scriptions of the successful use of the Venture catheter in extra-
coronary interventions; the first reported the use of this catheter
to cross a renal artery aneurysm8and the second described access
to a severe lesion in the popliteal bifurcation.17
This is the first reported use of the Venture wire control
catheter in the field of congenital heart disease. We used it in
order to cross a proximally migrated stent located in the pul-
monary trunk, perform left pulmonary artery stent placement,
and to identify and access an extremely angulated right stenosed
pulmonary vein insertion from transseptal approach.
The extensive use of different techniques, catheters and
guidewires to cross the stent in the first case demonstrated the
complexity and difficulty of the procedure. Moreover the ex-
treme angulation of the origin of the RPA, which is very com-
mon in patients with this defect, made introducing a wire in this
vessel challenging. It was particularly difficult in our patient due
to the dislodged stent lying in the pulmonary trunk. The use of
a balloon inflated at the origin of the RPA allowed for preferen-
tial movement of the wire to the LPA; however the cells of the
stent could not be crossed to permit the introduction of another
stent. The goal of the Venture catheter was to direct the wire to
the LPA after crossing the stent in a way that allowed us to reach
a distal pulmonary branch. With the earlier catheters and wires
used, the LPA was sometimes crossed adequately without pass-
ing through the stent cells but it was impossible to reach a distal
branch, probably due to the extremely acute angle required for
the wire.
In the second case, to cannulate the severely stenosed
medium and inferior right lobe vein insertion, we used the
Venture wire control catheter. This catheter allowed us to easily
Wire Control Catheter in CHD
Figure 4. Left pulmonary artery balloon dilatation using kissing balloon technique (A). Final angiography in craniocaudal posterior-anterior projection
showing successfully left pulmonary artery stent implantation (B). The previous stent rearranged towards the left pulmonary artery (C).
For Personal Use.
Copyright HMP 2012
E152 The Journal of Invasive Cardiology®
MANICA, et al.
identify the stenosed segment
after a small and selective hand
contrast injection and, after-
wards, to successfully access this
vessel with a 0.014" support
guidewire and proceed to pul-
monary vein dilatation. In ex-
tremely unstable patients like
those with pulmonary arterial
hypertension, any attempt to
simplify the procedure avoiding
extensive catheter manipulation
and contrast injection must be
seen with interest.
These illustrative cases are
examples of how coronary in-
terventional colleagues can help
interventional cardiologists in
the field of congenital heart dis-
ease to reach distal or ob-
structed vessels in the
pulmonary arterial or venous
tree, widening the scope of per-
cutaneous treatment of congen-
ital heart defects.
References
1. McClure SJ, Wahr DW, Webb JG.
Venture wire control catheter. Catheter
Cardiovasc Interv.2005;66(3):346-350.
2. McNulty E, Cohen J, Chou T, Shunk
K. A “grapple hook” technique using a
deflectable tip catheter to facilitate
complex proximal circumflex interven-
tions. Catheter Cardiovasc Interv.
2006;67(1):46-48.
3. Routledge H, Lefèvre T, Ohanessian A,
Louvard Y, Dumas P, Morice MC. Use
of a deflectable tip catheter to facilitate
complex interventions beyond insertion
of coronary bypass grafts: three case reports. Catheter Cardiovasc Interv.
2007;70(6):862-866.
4. Aranzulla TC, Sangiorgi GM, Bartorelli A, et al. Use of the Venture wire control
catheter to access complex coronary lesions: how to turn procedural failure into suc-
cess. EuroIntervention. 2008;4(2):277-284.
5. Iturbe JM, Abdel-Karim AR, Raja VN, Rangan BV, Banerjee S, Brilakis ES. Use of
the Venture wire control catheter for the treatment of coronary artery chronic total
occlusions. Catheter Cardiovasc Interv. 2010;76(7):936-941.
6. Brilakis ES, Lombardi WB, Banerjee S. Use of the Stingray guidewire and the Venture
catheter for crossing flush coronary chronic total occlusions due to in-stent restenosis.
Catheter Cardiovasc Interv. 2010;76(3):391-394.
7. Badhey N, Lombardi WL, Thompson CA, Brilakis ES, Banerjee S. Use of the Venture
wire control catheter for subintimal coronary dissection and reentry in chronic total
occlusions. J Invasive Cardiol. 2010;22(9):445-448.
8. Aranzulla TC, Colombo A, Sangiorgi GM. Successful endovascular renal artery
aneurysm exclusion using the Venture catheter and covered stent implantation: a case
report and review of the literature. J Invasive Cardiol. 2007;19(8):E246-E253.
9. Law MA, Shamszad P, Nugent AW, et al. Pulmonary artery stents: long-term follow-
up. Catheter Cardiovasc Interv. 2010;75(5):757-764.
10. O’Laughlin MP, Slack MC, Grifka RG, Perry SB, Lock JE, Mullins CE. Implantation
and intermediate-term follow-up of stents in congenital heart disease. Circulation.
1993;88(2):605-614.
11. Angtuaco MJ, Sachdeva R, Jaquiss RD, et al. Long-term outcomes of intraoperative
pulmonary artery stent placement for congenital heart disease. Catheter Cardiovasc In-
terv. 2011;77(3):395-399.
12. Driscoll DJ, Hesslein PS, Mullins CE. Congenital stenosis of individual pulmonary
veins: clinical spectrum and unsuccessful treatment by transvenous balloon dilation.
Am J Cardiol. 1982;49(7):1767-1772.
13. Tomita H, Watanabe K, Yazaki S, et al. Stent implantation and subsequent dilatation
for pulmonary vein stenosis in pediatric patients: maximizing effectiveness. Circ J.
2003;67(3):187-190.
14. Breinholt JP, Hawkins JA, Minich LA, et al. Pulmonary vein stenosis with normal
connection: associated cardiac abnormalities and variable outcome. Ann Thorac Surg.
1999;68(1):164-168.
15. Seale AN, Daubeney PE, Magee AG, Rigby ML. Pulmonary vein stenosis: initial ex-
perience with cutting balloon angioplasty. Heart. 2006;92(6):815-820.
16. Mueller GC, Dodge-Khatami A, Weil J. First experience with new drug-eluting bal-
loon for the treatment of congenital pulmonary vein stenosis in a neonate. Cardiol
Young. 2010;20(4):455-458.
17. Colantonio R, Latib A, Sangiorgi GM. Percutaneous treatment of a popliteal bifur-
cation – the value of coronary devices and strategies. Catheter Cardiovasc Interv.
2008;72(5):710-713.
Figure 5. Right-sided ostium injection demonstrating stenosis at the insertion of the right superior lobe drainage
(A). Venture catheter hand injection demonstrating the right medium and inferior vein insertion and severe
obstruction (B). Support 0.014" guidewires inserted through the venture catheter in superior and inferior right
pulmonary veins (C). Angiography showing increase in vessel diameter (D).
For Personal Use.
Copyright HMP 2012
