Difficulties in Transradial Intervention ( TRI).
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Difficulties in transradial intervention include failure to puncture the radial artery, radial artery spasm, tortuosity or loops in the radial or brachial arteries, use of smaller catheters, difficult coronary cannulation, and challenges during percutaneous coronary intervention. Proper catheter selection based on artery size and anatomy, use of adjunct devices like buddy wires, and deep intubation can help maximize support during difficult cases. Angiography may be needed to guide wiring and balloon crossing in tortuous vessels, and stenting can seal aortic dissections involving the coronary ostium.
Difficulties in Transradial Intervention ( TRI).
- 1. Difficulties in Trans Radial Intervention(TRI) Dr. Ashok Dutta FCPS (Med), MD(Card), FACC Associate Professor & Senior Consultant Dept. of Cardiology NHFH & RI , Dhaka
- 2. No Conflict of Interest.
- 3. Difficulties in TRI Difficulties are: 1. Failure to puncture RA. Gateway to PCI. 2. Radial artery spasm, 3. Radial artery tortuosity or loop, 4. Recurrent radial artery, 5. Brachial/BC artery loop/tortuosity, 6. Arteria lusoria, 7. Difficulty in coronary cannulation by GC (Platform for PCI). 8. Difficulties during PCI . Pathway to PCI RAO 60 with both table & I.I up is the convenient view to visualize the Brachio-Radial tree up to palmer arches.
- 4. Radial artery spasm 1. Wait for sometime, sedation, hydration, and pain relief. 2. Puncture at high up locations. 3. Distal Radial artery puncture- it filled up from palmar arch by ulnar artery. 4. Ulnar artery compression- increase the flow towards radial circulation. 5. Ulnar artery puncture. 6. Local S/C GTN .
- 5. Radial sheath is introduced but no back flush - 1. Very difficult and severe spasm . 2. Sheath is not in lumen - subintimal or outside the vessel in vascular sheath. So injecting saline or cocktail will go into tissue space and patient will feel pain. Better to go to Distal radial or Ulnar puncture. After puncture at snuff box and short wire introduction, before introducing sheath, radial sheath that was outside the lumen should be removed. Distal radial sheath act as hemostasis .
- 6. Upper limb vascular course are more unpredictable- (aorta-ileac vasculature) don’t push any hard ware against resistances.
- 7. For any resistance- proceed through fluoroscopic guidance specially when terumo wire is used and if needed angiogram may be helpful
- 8. Smooth GC tracking through brachia-radial tree- avoiding Razor Edge effect..
- 9. Brachiocephalic tortuosity and crossing from BC to ascending aorta. • For Catheter steerability 0.035 hydrophilic Terumo wire in tortuous brachiocephalic and angulated BC to Ascending aorta with TG/JL/PIG-Tail. • Once in ascending aorta, 0.035” regular wire for coronary cannulation for push-pull and rotation.
- 10. • Consider- 4 determinants • Radial artery diameter. • Aortic Anatomy- Diameter, Unfolding of aorta. • Take off of LCA & RCA. • Lesions characteristics. • With 7 F catheter(ID- 7X0.3=2.1 mm.): most purposes can be served. • 6 F catheter (ID-1.8mm)- 2 wire, 2 balloon , 2 stents , Rota bar up to 1.75 mm. TAP, Culotte, Crush – possible with all new wires and balloon. • 5 F catheter (ID-1.5mm) : 2 wires, 1 balloon, sequential dilatation is possible. Rota bar 1.25 mm . Stent up to 4 mm. used NC balloon > 4 mm may stuck at catheter tip. Aspiration catheter or Guidezilla can’t be passed. • Without good G.C support, doing PCI is difficult, may end up with complications and procedure failure . Difficulties in Coronary cannulation. Guide Cath. Selection GC is platform for PCI If you want peace, prepare for War.
- 11. Short Stature-Small aorta- smaller curve catheter. Dilated ascending aorta-larger curve catheter. LCA- EBU/XB, RCA- JR-3.5/AL-1. CXR P/A
- 12. DifficultiesduringPCI Difficulties in wire passing: CTO lesion, dissected lesion( pre existing or iatrogenic),SB wiring. • Multiple orthogonal views. • Gentle Wire manipulation. • Reshaping the wire tip. • Change the wire. • Micro catheter . Difficulties in balloon crossing the lesion (Un-crossable lesion): • Smallest & shortest size balloon (1.00- 1.25X6-8 mm). • Tornus- by rotation, may make a way for balloon. • Balloon-microcatheter hybrid (works like OTW balloon). • Anchor balloon technique. • Rota. Difficulties in balloon pre-dilatation( Un- crackable lesion)- calcified lesion : • Cutting balloon/scoring balloon ( angiosculp). • Buddy wire. • Wire-cutting technique, • Grenadoplasty (small balloon predilatation at high pressure till ruptured producing dissection. • 0.75-1:1 predilatation with NC balloon. • Rota/Shock wave. Difficulties in Stent delivery & post dilatation : • Deep intubation of G.C. ( risk of dissection) • Buddy wire- further predilatation with bigger NCB. • Anchor balloon ( side branch/distal anchoring). • GuideZilla/ Guide liner..
- 13. Maximization of Back-up support during TRI Summary • Cather type- (EBU/JR-4/AL-1) • For RCA- AL-1.0-1.5 >>> EB-R>>JR-3.5/4. • For LCA- EBU/XB/EBL >> JR • Cather Size – 7 Fr. >6Fr. > 5 Fr. • GC Curve- 4 curve >3.5>3 . • Deep intubation of catheter. • Use of adjunct device- Buddy wire, side branch wiring, anchor balloon, Guide Liner or Guide-Zilla (Mother & Child catheter) help in balloon negotiation and stent delivery.
- 14. G. Catheter selection- Support -get skilled with few GC only. TRA- GC in RCA less supportive. Judkins- JL-3.5/4.0, JR-3.5 XB/EBU-3.0/3.5/4.0 90 degree Primary curve=>. Less co-axial=> Never deeply engaged=>less ostial dissection. Free primary Curve=>more Co-axial=> deep engagement=> ostial trauma more. JR- 4 EBUJL AL 1
- 15. Size of the Catheter matters a lot. But in TRI use of large bore GC is limited smaller RA.
- 16. Buddy wire 5-6Fr. GC. • Useful in 5-6 Fr. GC. • Stabilizes the GC. • Support the passage of balloon for prediltation. • Helpful in Stent delivery. • Acts as a cutting balloon during predilatation – hard-calcified lesion crack. • May be used for distal balloon anchoring.
- 17. Anchor wire ê balloon Conal branch /RV branch. For fine cross or balloon negotiation and stent delivery. Buddy wire with distal main vessel anchoring for difficult stent delivery. Balloon size- 1.5-3.0 mm. 6-7 Fr. GC.
- 18. Deep intubation of GC. JR in RCA >> JL/EBU in LCA. Short LM > long LM. Chance of dissection if patient moves, breath deep, cough.
- 19. Guide Cath Extension- Mother & child catheter Guidezilla or Gude Liner. Balloon assisted . 6-7 Fr. GC.
- 20. Difficult PCI TR & TF approach • Anomalous Origin- specially RCA ( TIG and AL-1) . TRA is better for anomalous coronary. • Tortuous Coronaries. • Calcified vessels. • CTO. TFA >>TRA because of bigger GC & better support. • Bifurcation lesions. • LMCAD. • ACS- TRA is preferable because of less hematoma, liberty to use of Heparin, GP-IIb/IIIa inhibitors. • PCI in high Risk patient- Poor LVEF, arrhythmias, multiple comorbidities. • Difficulties related to wiring, balloon crossing & predilatation (un-crossable & un- crackable lesions), stent delivery, post-dilatation. • PCI related Complications. • Angiographic vs. procedural vs. clinical success.
- 21. Angioplasty in -tortuous vessel • Tips: • 7 Fr. Guide catheter , preferably Amplaz for RCA and EBU for LCA. • 2 wires give better stability. • All New York. Floppy wire, Sion, whisper . • Stent selection – shorter stent with good track ability is better than long single stent. If needed 2 stents may be used for long lesion. • Mother & child catheter (over the balloon) catheter may help to deliver the stent . • Pseudo-lesion/Concertina/accordion effect- sometime provokes to put unnecessary stents . • Pull back the floppy part of the PTCA wire up to the pseudolesion or put a Fine cross micro-catheter over the GW , then GW is removed. Fine cross is very much softer and flexible, take the shape of the artery and concertina effect will disappear.
- 23. Aorto-ostial dissection- How to tackle? • Not uncommon (incidence-0.08%), 2 times higher in TRA than TFA. • Amplaz is notorious to do it. XB>JL/JR. • Thrombus suction catheter & Guidezilla-may produce dissection if not properly aligned or balloon guided introduction is not done • Stenting ( covering the ostium) usually solves the problem. • Once dissection is noted, frequent and forceful contrast injection should be restricted to avoid extension of dissection in both direction. • As long as the GW is in lumen and catheter is stable , it’s possible to bailout the situation by stenting , covering the ostium. Sometimes to prevent distal extension , distally stenting may be required. • Compare to spontaneous aortic dissection, iatrogenic dissection extension of dissection is less rapid and less disastrous.
- 24. Aorto-ostial dissection- How to tackle. Middle aged male, RMI inferior. RCA-TO. Mid-LAD critical lesion. EF=50%. Wiring done by Run through floppy with fine cross. Severely tortuous artery. Predilatation done but no flow was established. So Aspiration was done. Flow established but dissection with stasis of contrast in sinus noted. Stent covering the ostium sealed it.
- 25. Aorto-ostial dissection- 37 yrs. M, F/H SCD. Mid LAD lesion Fixed. Dissection from ostium , extending spirally throughout the coronary tree. No further contrast/minimal puff. Wiring the LCx/LAD with free torck , try to enter any branches (ensuring true lumen), implant stent covering the Ostium.
- 26. Thank You