Hội Tim mạch học Việt Nam PCI support short

Strong guiding catheter with supportive wireEnough pre-dilatation or debulking Buddy wire or support wire Deeply engage or “amplatz” guiding Anchor technique Mother-child 5F catheter te

PCI for calcified and

tortuous vessels

Nguyen Ngoc Quang, MD, FASCC

Dept of Cardiology, Hanoi Medical University

Vietnam National Heart Institute

✓ The simpler procedure the better outcome

✓ Debulking device plays a small role except calcified or some special kinds of lesion (bifurcation, ostial, ISR…)

✓ Longer DES is frequently used (33, 38 mm…) - “from shoulder to shoulder” principle

✓ Safe DES implantation is important for long term outcome

Key Points in DES era

➠The deliverability of long stent is not good especially in the

calcified or tortuous lesion

Strong guiding catheter with supportive wire

Enough pre-dilatation or debulking

Buddy wire or support wire

Deeply engage or

“amplatz” guiding

Anchor technique

Mother-child (5F) catheter technique

Supports from guiding catheter

In complicated lesion we should initially use support catheter

instead of Judkins catheter

For RCA: AR, AL, Hockey, Champ, RCB

Supports from guiding catheter

In complicated lesion we should initially use support catheter

instead of Judkins catheter

For LCA: XB, EBU

Supports from guiding catheter

Stiffness

Pushing & pulling

of shaft, Torque control

Friction & slipping

Influencing factor of Back up support

Shape of catheter

λ = static friction within the aorta wall

F = back-up force

λ Fmax = ―――― cosθ

Ø If Fcosθ ≤ λ (static friction),

the guiding catheter works.

Ø If Fcosθ > λ, system collapses.

ØThus, Maximun backup force (Fmax) is:

Supports from guiding catheter

Supports from guiding catheter

Supporting point

Active point

Supports from guiding catheter

Supporting point

Active point

Supports from guiding catheter

Judkins L can generate greater backup force in TFI than in TRI

λ Fmax = ――――

cosθ

0 17.5 35.0 52.5 70.0

Supports from guiding catheter

Trans-radial （ Superior high take off）

Supporting

point

Active point

E 0

Supports from guiding catheter

Judkins L 3.5 can generate greater backup force in TRI than JL4.

λ Fmax = ――――

cosθ

0 11.3 22.5 33.8 45.0

Supports from guiding catheter

Ikari L can generate greater backup force than Judkins L in TRI

λ Fmax = ――――

cosθ

0 22.5 45.0 67.5 90.0

Considerations about the static friction

Supports from guiding catheter

Supports from guiding catheter

Engaging & power position

● Make the supporting point at lateral position of action & reaction

● Maintain the same direction with coronary artery ostium,

toward supporting point.

Supports from guiding catheter

Deep engagement increases backup force of Judkins Left.

λ Fmax = ――――

cosθ

0 12.5 25.0 37.5 50.0

Supports from guiding catheter

Power Position of Ikari L generates the greatest backup force

λ Fmax = ――――

cosθ

0 22.5 45.0 67.5 90.0

Power position Of Ikari Left

Pre-dilatation & pre-debulking

✓ Enough pre-dilatation

✓ Step by step dilatation

✓ Using higher pressure, larger, longer balloon

✓ Cutting balloon or balloon with buddy wire

✓ Rotablator (calcified lesion）

✓ DCA

✓Entire balloon surface contact the

vessel wall – arterial wall damage

✓Multiple rips and tears in media

✓Endothelium is completely

disrupted, large hematoma has

formed due to trauma

✓Injury localized to the scoring sites - reduced trauma

✓Media with no visible disruption

✓Endothelial layer remains intact

Pre-dilatation & pre-debulking

Acting mechanisms of Regular and Cutting balloons

Buddy wire or support wire

Deep engage - “amplatz” guiding

Using 5F straight guiding catheter

Deep seating 5F ST guiding catheter

0 20 40 60 80 100 120 140 160

8Fr only

Deep seating 5F ST guiding catheter

At 15 cm insertion from GC tip, 5F GC backup support is equal to 8F GC.

5F child catheter (20cm longer than mother catheter)

(5F ST GC - Terumo Co.)

Alternative 5F in 6F (7F) technique

6F (or bigger) mother catheter ID > 0.070 in

(without self-created side holes)

Child catheter can advance further to across the stenotic or tortous lesion → No risk of stent dislocation, stent deformity or DES

polymer peeling off, especially long stents

Using 5F straight guiding catheter

Potential complications

Vessel injury

• Gently advancement of child catheter into the coronary artery

Intra-coronary or intra-guiding catheter thrombus

• Careful monitoring distal coronary pressure

Air embolism

• Occur when child catheter is wedged, suck back too strong or angiography after stent deployment

• Check the blood back flow from Y-connector just after stent

deployment (Air embolism will

Using 5F straight guiding catheter

Using 5F straight guiding catheter

Using 5F straight guiding catheter

Anchor technique

Anchor technique

Anchor technique

Strong guiding catheter with supportive wire

Enough pre-dilatation or debulking

Buddy wire or support wire

Deeply engage or

“amplatz” guiding

Anchor technique

Mother-child (5F) catheter technique

✓ Appropriate choosing & manipulating GC is crucial for long, calcified and tortuous coronary lesions

✓ 5F guiding catheter or 5in6 GC system are alternative approaches for tortuous coronary lesions with long stents

✓ Combined approach (buddy wire, anchor technique, 5in6

GC system) is necessary for special case

Conclusions

Thank you very much

for your attention