Catheterization and Cardiovascular Diagnosis 39:96 (1 996)

Editorial Comment

Risks and Benefits of the Arani Curve Guiding Catheter for Stenting of the Right Coronary Artery: The Value of Experience David A. Clark, MD Stanford University, Stanford, California

Most interventional cardiologists with significant experience know that the most difficult anatomic situation to be faced in angioplasty is the “Shepherd’s Crook,” or “Omega” right coro- nary artery. Guiding catheter backup necessary to advance both wire and balloon to and across the lesion can sometimes thwart even the most experienced practitioner as guide after guide “backs out” when resistance is encountered in advancing the balloodwire combination. Modified Judkins Curves, Hockey Sticks, and oddly shaped catheters have been tried with varying degrees of success, but in plain old balloon angioplasty, the Arani Curve Double Loop Guiding Catheter is often the tool that achieves success. Now, in the wonderful world of stents, the problem has been magnified because of the increased resistance to passage along tortuous cor- onaries of the rigid stent and sheath combination that currently- and pending challenges to patent laws-for the foreseeable future, will provide episodes of frustration for interventionalists and risk for the patient. Dr. Arani and his colleagues now present a small series of cases

in which the use of a larger lumen version of the original Arani

Curves have effectively provided the strong backup needed to advance Palmaz-Schatz Stent Systems down difficult right coro- nary arteries. Their success rate is impressive, and the complica- tion rate is sufficiently low to warrant a revisitation of the Arani Curve as an important adjunct to standard right coronary guiding catheters.

A secondary point made in Dr. Arani’s paper is the propensity of the extra support wire to cause spasm in the lumen of the artery. This is a common and identifiable phenomenon with the extra support wire, and should be recognized and treated with removal of the wire. If the operator is not able to distinguish between spasm and dissection on the video screen, under these circumstances a Tracker Catheter could be put over the extra support wire, the wire removed and replaced with a usual 0.014 wire, and then injections repeated to assess the continuing presence or absence of filling defects.

But, a word of warning. The reporting group undoubtedly con- stitutes the largest experience in the world in handling and posi- tioning these strong, but potentially dangerous tools. As with any interventional technique, experience is a dominant factor in suc- cess and safety. The manipulation and positioning of the Arani Guide takes tactile experience in handling the catheter, the excel- lent figures presented with the current and previous papers from Dr. Arani notwithstanding. While I do advocate the use of this guide to achieve success in difficult cases, the guide should be handled by senior physicians, and in each group perhaps one in- terventionalist should become the expert in the Arani technique, thereby diminishing the likelihood of catheter induced trauma to the ostium and proximal areas of the right coronary artery, and increasing the likelihood of success.

0 1996 Wiley-Liss, Inc.