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J Am Coll Cardiol, 1998; 32:1861-1865
© 1998 by the American College of Cardiology Foundation
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CLINICAL STUDIES

Scraping of aortic debris by coronary guiding catheters

A prospective evaluation of 1,000 cases

EllenC Keeley, MDa and CindyL Grines, MD, FACCa

a Department of Internal Medicine (Cardiovascular Division), William Beaumont Hospital, Royal Oak, Michigan, USA

Manuscript received April 10, 1998; revised manuscript received July 31, 1998, accepted August 20, 1998.

Address for correspondence: Dr. Cindy L. Grines, Director of Cardiac Catheterization Laboratories, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, Michigan 48073
cgrines{at}beaumont.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Objectives. This study was designed to determine the incidence and to quantitate aortic debris retrieved during placement of guiding catheters in patients undergoing percutaneous interventions.

Background. Studies have shown that atherosclerotic aortic debris predisposes patients to spontaneous or procedurally related ischemic events.

Methods. In 1,000 consecutive percutaneous interventions, the amount of visible atheromatous material from large-lumen-guiding catheters was recorded. Clinical characteristics and in-hospital complications were prospectively collected and associated with debris production.

Results. Visible aortic debris (1+ to 3+) occurred more frequently with the Judkins left (JL) catheter, followed by the multipurpose (Multi) catheter compared to any other type of guiding catheter (65%, p = 0.001 and 60%, p = 0.01, respectively). Large debris (2+ and 3+) was observed most frequently with the Multi (odds ratio 3.79, C.I. = 2.32 to 6.21, p = 0.001), JL (odds ratio 2.83, C.I. = 1.98 to 4.05, p = 0.001) and voda left (VL) (odds ratio 2.73, C.I. = 1.51 to 4.95, p = 0.001) catheters. The Judkins right (JR) catheter type was least likely to produce any debris (24%, p = 0.001). A history of unstable angina (p = 0.05) or myocardial infarction (p = 0.003) was associated with a decreased incidence of debris production. The presence of debris was not found to be associated with in-hospital ischemic complications.

Conclusions. Studies have shown that atherosclerosis of the aorta is a potential source of systemic embolism in patients undergoing cardiac catheterization. Our study shows that in more than 50% of percutaneous revascularization procedures, guiding catheter placement is associated with scraping debris from the aorta. Design characteristics of the JL, Multi and VL guiding catheters make them most likely to produce such debris. Meticulous attention to allow the debris to exit the back of the catheter is essential to prevent injecting atheromatous debris into the vascular bed.

Abbreviations and Acronyms
  AL = Amplatz left
  AR = Amplatz right
  HS = hockey stick
  JL = Judkins left
  JR = Judkins right
  LIMA = left internal mammary artery
  Multi = multipurpose
  VL = voda left

The aorta is the most frequent source of arterial atheromatous emboli. Aortic arch plaques are recognized as an independent risk factor for stroke (1–7). Plaques in the thoracoabdominal aorta can embolize to the visceral arteries and limb circulation causing mesenteric ischemia, renal insufficiency and vascular complications (8–15).

Atheromatous material within the aorta may be dislodged during invasive aortic procedures (16). Transesophageal echocardiographic recognition of atherosclerotic aortic debris identifies patients at high risk for stroke and peripheral embolism during cardiac catheterization, intraaortic balloon pump placement and cross-clamping of the aorta during coronary bypass surgery (17–28). The incidence of clinically apparent embolization and stroke associated with diagnostic cardiac catheterization is less than 1% (29). However, the incidence of catheter-related embolism in necropsy studies has been reported to be as high as 30% (30,31).

The overall complication rates of percutaneous revascularization procedures are higher than diagnostic catheterization (29). In patients undergoing percutaneous interventions, stiff, large-bore-guiding catheters are used. These design characteristics can be more traumatic to the aorta than diagnostic catheters, which are more flexible, have smaller lumens and tapered tips. We noticed that during advancement of guiding catheters, atheromatous debris scraped from the aorta exited the back of the catheter. This was almost never seen during diagnostic catheterization.

This study was designed to determine the incidence and to quantitate aortic debris (atheromatous material that exited the guiding catheter during its advancement into the descending aorta and around the aortic arch) retrieved in 1,000 consecutive patients undergoing percutaneous interventions. We sought to determine whether there were patient or catheter characteristics that predispose to the presence of aortic debris, which, if inadvertently flushed forward, may embolize. Finally, we determined whether the presence of debris was associated with in-hospital recurrent ischemia, myocardial infarction, acute renal failure or ischemic neurologic complications.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Patients.   In 1,000 consecutive percutaneous interventions, the amount of visible atheromatous material from large-lumen (8 and 9F) guiding catheters was recorded. To identify the clinical characteristics associated with visible atherosclerotic debris, data were prospectively collected on a standardized form. Gender, age, diabetes mellitus, hypercholesterolemia, smoking, hypertension, peripheral vascular disease, chronic renal insufficiency, chronic stable angina, unstable angina, history of myocardial infarction, history of transient ischemic attack and cerebral vascular accident, and history of coronary artery bypass surgery were documented (Table 1). In-hospital complications including myocardial ischemia, myocardial infarction, acute renal failure, and ischemic neurologic complications were prospectively collected and analyzed (Table 2).


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  		Table 1 Multiple Logistic Regression Analysis of the Clinical Variables With the Presence of Any Debris (1+ to 3+)

 

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  		Table 2 Multiple Logistic Regression Analysis of In-Hospital Complications With Presence of Any Debris (1+ to 3+)

 
Catheter technique.   After the guiding catheter was advanced over an 0.035-inch wire into the descending aorta and around the aortic arch, the wire was removed, blood was allowed to exit the back of the catheter for at least three cardiac cycles and was collected on a sterile towel. This was visualized by the operator for the presence and relative quantity of atheromatous material. The Y-connector system was then attached to the guiding catheter and coronary angiography with subsequent percutaneous revascularization was performed. A visual scoring system was devised to describe the amounts of atheromatous material termed aortic "debris." The scoring system consisted of a score from 0 to 3, where 0 = no visible debris; 1+ = fine, crystal-like sparkles; 2+ = one or two solid particles 0.5 to 2 mm in diameter; and 3+ = greater than three such particles or debris larger than 2 mm in diameter (Figs. 1–3). Catheter shapes and "debris scores" were recorded for all 1,000 procedures (Fig. 4 and 5, Table 3).



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  		Figure 1 Gross pathologic features of fine, crystal-like atheromas termed 1+ debris.

 


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  		Figure 2 Gross pathologic features of solid atheroma termed 3+ debris.

 


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  		Figure 3 Gross pathologic features of 1+ (middle arrow), 2+ (bottom arrow) and 3+ (top arrow).

 


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  		Figure 4 Debris scores expressed as percent of total debris for each catheter type. AL = Amplatz left; AR = Amplatz right; HS = hockey stick; JL = Judkins left; JR = Judkins right; LIMA = left internal mammary artery; Multi = multipurpose; VL = voda left; *p value <0.05 relative to any catheter; thus, JR catheters scrape less debris, and Multi and JL catheters scrape significantly more debris than does the average guiding catheter. Debris score: open columns = 1+; striped columns = 2+; solid columns = 3+.

 


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  		Figure 5 Odds ratios and confidence intervals for the production of 1+, 2+ and 3+ debris, relative to the JR catheter. AL = Amplatz left; AR = Amplatz right; HS = hockey stick; JL = Judkins left; JR = Judkins right; LIMA = left internal mammary artery; Multi = multipurpose; VL = voda left.

 

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  		Table 3 Overall Incidence of Debris According to Catheter Type

 
Statistics.   Data are reported as mean ± SD. Multiple logistic regression analysis was performed using the SAS System (version 6.12) to compare the clinical profile of patients, the type of catheter used, the presence and relative amount of aortic debris produced and in-hospital complications. A p value <0.05 was considered significant.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Visible aortic debris (1+ to 3+) occurred more frequently with the Judkins left (JL) type guiding catheter, followed by the multipurpose (Multi) catheter compared to any other type of catheter (65%, p = 0.001, and 60%, p = 0.01, respectively) (Fig. 4, Table 3). The voda left (VL) was associated with debris production, but did not reach statistical significance (55%, p = 0.11) (Fig. 4, Table 3). Relative to the Judkins right (JR) catheter, minor debris (1+) was observed most frequently with the voda left (odds ratio 2.56, C.I. = 1.42 to 4.61, p = 0.003); hockey stick (HS) (odds ratio 2.47, C.I. = 1.43 to 4.55, p = 0.005); Amplatz right (AR) (odds ratio 2.11, C.I. = 1.07 to 4.15, p = 0.038); and JL (odds ratio 1.73, C.I. = 1.21 to 2.49, p = 0.002) catheters (Fig. 5). Large debris (2+ and 3+) was observed most frequently with the Multi (odds ratio 3.79, C.I. = 2.32 to 6.21, p = 0.001), JL (odds ratio 2.83, C.I. = 1.98 to 4.05, p = 0.001), VL (odds ratio 2.73, C.I. = 1.51 to 4.95, p = 0.001) and Amplatz left (AL) (odds ratio 2.49, C.I. = 1.42 to 4.33, p = 0.002) catheters (Fig. 5). The JR catheter was the catheter least likely to produce debris regardless of amount (24%, p = 0.001) (Fig. 4, Table 3).

A history of unstable angina or previous myocardial infarction was associated with a decreased incidence of any debris production (odds ratio .869 and .810, respectively) (Table 1). When analyzed according to size of debris particles (1+ to 3+), no additional significant association was seen between the presence or size of debris particles and increasing age of the patient. In-hospital recurrent ischemia, myocardial infarction, acute renal failure or ischemic neurologic complications occurred infrequently, and these were not associated with the presence or size of debris particles (1+ to 3+) (Table 2).


   Discussion
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 Abstract
 Methods
 Results
 Discussion
References
 
Atheromatous lesions in the aorta have been shown to occur in half of middle-aged men and in one-third of women, and the prevalence continues to increase in the subsequent decades of life (4,30). Previous studies have shown that the presence of atheromatous material in the aorta (aortic debris) increases the risk of systemic embolization and stroke during cardiac catheterization (28) and also procedures that involve aortic manipulation such as coronary artery bypass surgery (23–27). When aortic debris is detected, substituting brachial for femoral catheterization and avoiding placement of an intraaortic balloon pump have both been recommended to reduce the risk of embolism.

Embolic complications, although infrequent, appear to account for a significant portion of the morbidity and mortality of coronary interventions. They are thought to be the result of clot formation due to prolonged procedures, but they may also be due to dislodgment of atheromatous material from the aorta during catheter and wire manipulation. During percutaneous interventions, large-lumen, stiff-guiding catheters are used. Atheromatous material frequently exits the back of the guiding catheters during their advancement in the descending aorta and around the aortic arch. This study was designed to describe the incidence of aortic debris, to semi-quantitate the amount of aortic debris, to determine whether patient or catheter characteristics have any bearing on debris production, and to determine if the presence of aortic debris is associated with in-hospital complications.

Our data show a high incidence of aortic debris scraped by the guiding catheter (51% of cases overall) but a wide range depending on the shape of the catheter used (24% to 65%). The JL and Multi guiding catheters were associated with a significant increase in overall aortic debris production, particularly large debris, visible at the time of catheter advancement compared to the other guiding catheters evaluated. Voda left catheters also tended to be associated with debris but did not reach statistical significance, likely due to a small sample size. However, when large debris was observed, the voda left catheter (similar to the Multi and JL catheters) was more likely to be responsible. We postulate that the shapes of the JL, Multi and VL catheters are more traumatic to the aorta owing to their long secondary curves, acting as "atherectomy devices" as they pass across friable plaques. The JR catheters were the least likely to lead to debris production.

Interestingly, the patient population at decreased risk for debris production were patients with unstable angina or a history of myocardial infarction. This may be due to a more thrombotic and less atherosclerotic process leading to the acute ischemic syndrome, or lifestyle and medication modification with atherosclerotic regression in the postmyocardial infarction patients.

The presence of aortic debris was not found to be associated with the in-hospital complications of recurrent ischemia, myocardial infarction, acute renal insufficiency or neurologic ischemic complications regardless of the relative size and amount. This may be due to the technique used in this study where all guiding catheters were allowed to bleed back onto a sterile towel after wire removal and prior to attachment of the Y-connector. This technique theoretically could decrease the incidence of embolizing atheromatous material forward into the coronary or cerebral or peripheral circulation. Moreover, the small event rate and innumerable other factors contributing to complications will make the relationship between debris and clinical events difficult to ascertain.

Study limitations.   This study has several limitations: 1) all patients included in the study had significant coronary artery disease; therefore, this selection bias may explain why the study failed to demonstrate an association of aortic debris with traditional risk factors for atherosclerosis; 2) the semiquantitative, subjective nature of the "debris score"; 3) none of the patients underwent transesophageal echocardiography at the time of the percutaneous procedure; therefore, it is unknown whether the debris produced by advancement of the catheter within the aorta is representative of the extent of aortic atherosclerosis; and 4) the overall risk of complications during percutaneous interventions is low; consequently, an extremely large sample size would be required to determine whether visible debris correlates with ischemic complications.

Conclusions.   Previous studies have shown that atherosclerosis of the aorta is a potential source of systemic embolism, particularly in patients undergoing manipulation of the aorta such as coronary artery bypass surgery and cardiac catheterization. Our study shows that scraping atherosclerotic debris into large lumen-guiding catheters is common and seems to be related to catheter design. Using Judkins left, multipurpose, or voda left guiding catheters during percutaneous revascularization procedures increases the likelihood of dislodging debris from the aorta. Recognition of this phenomenon, and allowing sufficient "back bleeding" from the guiding catheter after wire removal and before attaching the Y-connector, is essential to avoid embolizing atheromatous debris during contrast injections.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Schechtman KB, Kouchoukos NT. Atherosclerosis of the ascending aorta: prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke. 1994;25:2010–2016[Abstract]
  2. Jones EF, Kalman JM, Calafiore P, Tonkin AM, Donnan GA. Proximal aortic atheroma: an independent risk factor for cerebral ischemia. Stroke. 1995;26:218–222[Medline]
  3. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331:1474–1479[Abstract/Free Full Text]
  4. Amarenco P, Duyckaerts C, Tzourio C, Henin D, Bousser MG, Hauw JJ. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med. 1992;326:221–225[Abstract]
  5. Mitusch R, Doherty C, Wucherpfennig H, et al. Vascular events during follow-up in patients with aortic arch atherosclerosis. Stroke. 1997;28:36–39[Abstract/Free Full Text]
  6. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke: the French study of aortic plaques in stroke group. N Engl J Med. 1996;334:1216–1221[Abstract/Free Full Text]
  7. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996;335:1857–1863[Abstract/Free Full Text]
  8. Kempczinski RF. Lower-extremity arterial emboli from ulcerating atherosclerotic plaques. JAMA. 1979;241:807–810[Abstract]
  9. Deschamps P, Leroy D, Mandard JC, Heron JF, Lauret P. Livedo reticularis and nodules due to cholesterol embolism in the lower extremities. Br J Dermatol. 1977;97:93–97[CrossRef][Medline]
  10. Bourdages R, Prentice RS, Beck IT, Dacosta LR, Paloschi GB. Atheromatous embolization to the stomach: an unusual cause of gastrointestinal bleeding. Am J Dig Dis. 1976;21:889–894[CrossRef][Medline]
  11. Carnevale NJ, Delany HM. Cholesterol embolization to the cecum with bowel infarction. Arch Surg. 1973;106:94–96[Medline]
  12. Coy KM, Maurer G, Goodman D, Siegel RJ. Transesophageal echocardiographic detection of aortic atheromatosis may provide clues to occult renal dysfunction in the elderly. Am Heart J. 1992;123:1684–1686[CrossRef][Medline]
  13. Tilley WS, Harston WE, Siami G, Stone WJ. Renal failure due to cholesterol emboli following PTCA. Am Heart J. 1985;110:1301–1302[CrossRef][Medline]
  14. Zatuchni J, Patel HK, Chiemchanya S. The "blue toe" syndrome associated with renal atheroembolism and failure. Angiology. 1985;36:209–214[Abstract/Free Full Text]
  15. Coppeto JR, Lessell S, Lessell IM, Greco TP, Eisenberg MS. Diffuse disseminated atheroembolism: three cases with neuro-ophthalmic manifestations. Arch Ophthalmol. 1984;102:225–228[Abstract]
  16. Ramirez G, O’Neill WM, Lambert R, Bloomer HA. Cholesterol embolization: a complication of angiography. Arch Intern Med. 1978;138:1430–1432[Abstract]
  17. Horowitz DR, Tuhrim S, Budd J, Goldman ME. Aortic plaque in patients with brain ischemia: diagnosis by transesophageal echocardiography. Neurology. 1992;42:1602–1604[Abstract/Free Full Text]
  18. Toyado K, Yasaka M, Nagata S, Yamaguchi T. Aortogenic embolic stroke: a transesophageal echocardiographic approach. Stroke. 1992;23:1056–1061[Abstract/Free Full Text]
  19. Tunick PA, Kronzen I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J. 1990;120:658–660[CrossRef][Medline]
  20. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ Jr, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol. 1991;17:73–78[Abstract]
  21. Tunick PA, Rosenzweig BP, Katz ES, Freedberg RS, Perez JL, Kronzon I. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol. 1994;23:1085–1090[Abstract]
  22. Khoury Z, Gottlieb S, Stern S, Keren A. Frequency and distribution of atherosclerotic plaques in the thoracic aorta as determined by transesophageal echocardiography in patients with coronary artery disease. Am J Cardiol. 1997;79:23–27[CrossRef][Medline]
  23. Marschall K, Kanchuger M, Kessler K, et al. Superiority of transesophageal echocardiography in detecting aortic arch atheromatous disease: identification of patients at risk of stroke during cardiac surgery. J Cardiothorac Vasc Anesth. 1994;8:5–13[Medline]
  24. Wareing TH, Davila-Roman VG, Barzilai B, Murphy SF, Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations: a strategy for detection and treatment. J Thorac Cardiovasc Surg. 1992;103:453–462[Abstract]
  25. Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992;20:70–77[Abstract]
  26. Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg. 1992;53:758–761[Abstract]
  27. Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Kouchoukos NT. Intraoperative ultrasonographic evaluation of the ascending aorta in 100 consecutive patients undergoing cardiac surgery. Circulation. 1991;84(Suppl III):III-47–III-53
  28. Karalis DG, Quinn V, Victor MF, et al. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J. 1996;131:1149–1155[CrossRef][Medline]
  29. Noto TJ, Johnson LW, Krone R, et al. Cardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions. Cathet Cardiovasc Diagn. 1991;24:75–83[Medline]
  30. Sternby NH. Atherosclerosis in a defined population: an autopsy survey in Malmo, Sweden. Acta Pathol Microbiol Scand. 1968;(Suppl 194):1–216
  31. Moldreen-Geronimus M, Merriam JC Jr. Cholesterol embolism: from pathological curiosity to clinical entity. Circulation. 1967;35:946–953[Abstract/Free Full Text]



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