Curtis s T. Stin is , M.D., F.A.C.C., F.S .C.A.I.Direc tor, Periphera l In te rventions

Direc tor, In te rventiona l Cardiology Fellows hip

Divis ion of Cardiology

Scripps Clinic

La J olla , CA

Key Tips for Succes s

•A s ummary of s ome key tips and tricks for s o lvingcommonly encountered and complex problems inthe ca th lab

•Having thes e tricks in your bag can he lp make acomplex cas e go more s mooth ly

Radia l vs . Femora l

•Radia l “ firs t” s tra tegy:Patien t comfort

Les s b leed ing

Same day dis charge , even pos t-PCI

No need to tie up s ta ff fo r gro in ho lds

As s oc ia ted with lower overa ll cos t

•Femora l acces s for:Complex ana tomy

Extreme tortuos ity, ca lcifica tion, multiple previous s tents , CTOs

Need for hemodynamic s upport device

Known rad ia l/b rachia l/s ubc lavian tortuos ity or a rte rialus oria

What French Size Should I Us e?

• 6 French s ys tem:No tortuos ityBifurca tions tha t will no t requ ire 2 s imultaneous s tentsNot ca lc ifiedNot very dis ta lNo previous s tents to naviga te through

• 7 French s ys tem:Extra s upportSimultaneous s tents / complex bifu rca tions

• 8 French s ys tem:Exce llent s upportSimultaneous ba lloons /s tentsCa lc ified les ions : More Rotabla tor op tions

1.25mm 1.5 mm 1.75 mm 2.0 mm

6 Fr 7 Fr 8 Fr

Managing Tortuous Iliacs

•Us e Wholey/Vers acore wire (with a bend) ins ide J R4to naviga te up iliacs , then exchange for Ampla tzwire

•Us e a long bra ided s hea th (ie : Arrow) with a gu ideca the te r 1 French size smaller

Les s fric tion in s ys tem

Eas ie r to to rque

•Us e 0.63 wireKeeps guide from kinking

Improves to rqueab ility

I Can ’t De liver Balloon/Sten t!

•Larger French Sys tem (s hould have done it in the firs t p lace!)Can exchange over s tiff gu idewire (ie : Grands lam, Mailman)

•AL1 for RCA vs . J R4 with GuideLiner/GuidezillaAL1 good s upport bu t ris k for proximal d is s ec tion and acute AI

Guide line r/Guidezilla with J R4 a llows variable s upport and eas ie rPCI of os tia l le s ions

•Buddy wire

•Wiggle wire

•Buddy BalloonNon-infla ted

Infla ted : “ Anchor ba lloon ”

•Guide liner/Guidezilla

•Us e multip le s horte r s ten ts

•Combina tions of the above

The Guide liner/Guidezilla :A Game Changer

•“ Torpedo ” techniqueAdvance Guide liner/Guidezilla d is ta lly us ing an

infla ted ba lloon a t tip as a s oft d ila to r

•“ Variab le Guide ” techniqueCan us e with a les s s upportive gu ide (ie : J R4)

and us ed to vary s upport fo r dis ta l vs . proxima lin te rventions

•Often us e 6Fr ins ide a 7Fr or 8Fr guideCan pas s 6Fr Guide liner/Guidezilla deeper in to

ves s e l

Allows be tte r gu ide s upport

•Can a ls o be us ed to min imize contras texpos ure and as an “ uns hea thing ” too l

Variab le Guide Technique

•Tortuous RCA

•Dis ta l le s ion

•AL1 deep-s ea tedin to RCA

•Sten t will no t ge tpas t mid RCA dueto tortuos ity

•“ Anchor” ba lloontechn ique

•Buddy wireadvanced intodis ta l RCA

•2.75mm compliantba lloon advancedover buddy wirein to d is ta l RCA andinfla ted

•Sten t can now beadvanced over firs twire in to d is ta lRCA

•Buddy wire andba lloon thenremoved

•Sten t pos itionedacros s les ion anddeployed

•Fina l Res ults

•Tortuous RCAwith d is ta ld is eas e…

•Proximal RCA hasmild d is eas e

•Calc ified mid RCA

•Very tortuousIliacs …

2 diagnos ticca the te rs kinkedtrying to engageRCA!!

•8Fr Long Arrowbra ided s hea thwith 7Fr J R4 guide

•“ Gardenhos e ”us ed to torqueca the te r in to RCAwithout kinking

•6Fr Guideline r

•Wired in itia lly withOTW balloon andPilo t 50 wire

•Pilo t 50exchanged forWiggleWire

•Shorte r s ten t us edbecaus e longerone wouldn ’t track

•Note“ Amplatzifica tion ”of J R4 guide withGuideLiner

•Second s horters tent advanced

•Dis ta l RCAappearance afte r 2overlapping s tentsplaced

•Guide line rre trac ted back toaddres s mid /proxdis eas e

•Tortuous andecta tic RCA

•Calc ified proximaland dis ta l le s ions -previous opera to runable to d ila tewith non-complian tba lloon!

•8Fr AL1

•1.5mm Burr

•1.5mm Burr

•In itia l p lan to trea td is ta l le s ion firs tbu t…

Balloons /s tentswould not ge t pas tproximal les ion!

Sten t proximalles ion firs t!!

•4mm DESdeployed

•Pos t-d ila ted with6mm balloon

•Appearance afterproximal s tentdep loyment

•“ Torpedo ”techn ique

•6Fr GuideLineradvanced throughproximal s tentedarea us ing 2.5mmcompliant ba lloonas a s oft d ila to r

•Dis ta l le s ion pre -dila ted with non-compliant 4mmballoon

•Not going todila te? ? ?

•4mm DESpos itioned anddeployed

•Pos t-d ila ted with6mm non-compliant ba lloon

•Minimal con tras tin jec tion requiredto s ee d is ta l ves s e lwell

•Fina l res u lts

•Dis ta l flow knownto be exce llentfrom previousdis ta l GuideLinerin jec tion

I Can ’t Engage the Coronary!

•Can engage with diagnos tic ca the te r, but no t with aguide

Engage with d iagnos tic cathe te r, then wire coronary withs tiff/s upportive wire and then exchange care fu lly for thegu ide

•Can s ee the coronary, but can t d irec tly engage itwith d iagnos tic ca the te r or guide

Make a cus tom gu ide us ing hea tgun

•Can ’t to rque ca the te r we ll enough to engageLong s hea th / gu ide 1 Fr s ize s malle r

“ Gardenhos e ” .063 wire

Go from rad ia l approach if iliacs too s evere

I Can ’t Engage the Coronary!

•Gently focus heat in a rea to bebent

•Avoid melting cathe te r!

•Avoid burning yourse lf!

•Quickly dip into flush ba th tocool it and “freeze ” shape

•Anomalous LCX

•Dis eas edanomalous LCX

•Where exac tlydoes it come off?

•Pos te rio r takeoffvery c los e /s haredwith RCA

•J R4 in itia lly tried

•Keeps d iving in toRCA too deep toengage anomalousLCX

•Guidewireins erted in to RCAto he lp s tab ilizeJ R4

Cus tom Multi-purpos e Cathe te r

•Tip partia lly bent so as not toengage too deeply into RCA

•Coronary cannotbe engageddirec tly by cus tomguide , s oGrands lamins erted in to RCAvia J R4 and J R4exchanged out forcus tom guide

•Cus tom guide s itsa t the os tium ofRCA and does notdive too deep lyin to RCA

•Allows LCX to bewired withhydrophilic wire

•Dis ta l le s ion pre -dila ted withcompliant ba lloon

•6Fr GuideLinerus ed to de live rs tent in to d is ta lLCX

•Guide line rwithdrawn toexpos e next a reato be s ten ted

•Second s tentpos itioned anddeployed

•Fina l res u lts

•Anomalous RCA

•NSTEMI culpritves s e l

•Extremelytortuous iliacs ys tem andas cending aorticaneurys m

•Multip le ca the tersus ed in an a ttemptto engage RCA

•This is the c los es tto engagement

•Can s ee it….

•But can ’t engageit!

•Partia lly engagedRCA, but pops outnearly immedia te ly

•Left rad ia lapproach to avoidextremely tortuousiliac s ys tem

•Cus tom multi-purpos e guidecrea ted withhea tgun to a llowenough reach toengage RCA

•Pilo t 50 wire us edto wire ves s e lca refu lly

•OTW balloonwould not travers etortuos ity

•Cors a ir ca the te rs ucces s fullyadvanced intodis ta l ves s e l

•Pilo t 50exchangedthrough Cors a ir fo ra Wigglewire

OTW Balloon Wont Go?Use Specialty Support Catheter

• Much more trackable than an OTWballoon

• Can spin Corsa ir and Turnpikeca the te rs to reduce coefficient offriction to cross les ions eas ie r

•Les ion pred ila ted

•Improved flow

•Sign ificantproximaltortuos ity!

•From anothervantage poin t

•Sten t advancedacros s les ion

•Sten t deployed

•Non-compliantba lloon will no tadvance throughs tent s tru ts

•“ Torpedo ”techn ique us ed toadvanceGuideLiner in toprox RCA

•Non-compliantba lloons ucces s fullyde live red

•Fina l Res ults

It’s Not a CTO but…I Can ’t Wire This Ves s e l!

•Wire won ’t to rque or pro laps es ?Us e an OTW s ys tem for s upport

Hydrophilic wires to rque eas ie r and c ros s calc ified/tortuousles ions eas ier

BUT can a ls o “ ge t beh ind ” plaque eas ie r and caus e ves s e lc los ure /d is s ec tion

•Extreme tortuos ity?Venture ca the te r

•Severe dis eas e /d is s ec tion?Carefu l us e of hydrophilic s oft wires

Us e of the “ progres s ive true lumen ” approach

•NSTEMI

•Tortuous iliacslong 8Fr shea th with7Fr guide

•Graft to LAD closed

•Severe na tive LADles ion

•35 mins of flurospent trying to wireLAD….

•Wires successfullyinse rted into septa land diagonal, but notLAD!

•Poor flow and?dissection in LAD

•Further a ttempts towire LAD areunsucces sful- wiresgo into dissectionplane

•Decis ion made toballoon os tium ofsepta l acrossongoing LAD with 2.0mm balloon

•Wire partia llyinse rted into LAD,but not free andappears to be indissection plane

•Wire le ft in LADdissection plane

•Fourth wireadvanced into smallsepta l branch tha tcomes off LADdowns tream of thela rge firs t septa lbranch

•Small septa l dila tedwith 1.5mm balloon

•Small septa l comesoff true lumen of LADjus t downs tream ofla rge firs t septa l

•OTW balloonadvanced into smallsepta l branch andwire exchanged forhydrophilic wire with90 degree bend

•Afte r hydrophilicwire advanced intotrue lumen of dis ta lLAD, OTW balloonadvanced and wireexchanged for BMW

•Balloon angioplas tyof LAD performed

•Appearance afterangioplas ty…

•Fina l results a fte rs tent placement

“ Progres s ive True Lumen Approach ”

Target Ves s e l

Can ’t pas swire due todis s ec tion orplaque

Wire s malls idebranchoff true lumen

Dila te intos idebranchand exchangewire for 90degree bendor angledcatheter

Carefullyredirec t wireinto truelumen

Dila te ands tent intotarget ves s e l

#1

#2#3#4

Uh Oh… I Have a Perfora tion!

•Good prac tice to take a s mall “ puff” afte r a ba lloonis defla ted to be s ure there is no perfora tion

•If perfora tion noted , FIRST th ing to do is re -ins ertba lloon and tamponade the bleed

•Cons ider revers ing heparin with pro tamine , s topAngiomax

•J oStents can be very difficu lt to de liver!Get s econd acces s - VERY importan t!

Leave ba lloon up from firs t gu ide while s econd guide ispos itioned

“ Dueling Guide ” techn ique

•LAD stent deployed

•Uh oh….

•Fortunate ly, ba lloons till in place

•Immedia te ly infla teba lloon totamponade bleeding

•Balloon left up whilesecond accessobta ined with 8Frguide

•Second guidebrought into pos ition

•Wire from secondguide brought downto ba lloon, ba lloonquickly defla ted, wirepassed, then balloonre infla ted

•JoStent advancedinto prox LAD

•Balloon defla ted andquickly withdrawninto guide andJoStent quicklyadvanced intopos ition

•Jos tent deployed

•Perfora tion sea led!

I Have Sten t Regre t!

•Deployed a s ten t, but now it wont expand!High pres s ure ba lloon infla tion

Rotab la to rUse 2mm burr and GO SLOW- don ’t advance too hard….. Or burr can get

trapped!

(OFF LABEL!)

Las er techn iqueUse 0.9mm laser ca the ter with contras t infus ion ra ther than saline

(OFF LABEL!)

•Dis ta l RCA disease

•Les ion seems toexpand with 2.75mmballoon

•3.0mm stentdeployed to 18 Atm

•Second 3.0mm stentdeployed jus tproximally

•3.25mm non-compliant ba lloon to30 Atm!!

•0.9mm laserca the te r

•Contras t infusedra ther than sa line

•?micro bubbles!!

•Expands now with3.25mm non-compliant balloon!

•2.5mm stent a t PDAos tium

•Fina l Results

Thank You