Nolan J
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Dr. Jim Nolan from University Hospital of North Staffordshire presented at the Rencontres Interventionnelles conference in Prague, Czech Republic in 2011. The presentation discussed challenging radial artery cases and how to treat them. Some of the key issues discussed included the influence of forearm arterial anatomy on outcomes, subclavian issues, backup strategies, and challenging cases. Dr. Nolan advocates acquiring an arm angiogram after sheath insertion to plan the optimal procedure and reduce risks. He discusses different anatomical variations like high bifurcations and loops, and their increased risks. Strategies presented to deal with variations included minimizing catheter size and exchanges, considering 5F guiding catheters, and sheathless guides. Rare variations like retroes
Nolan J
- 1. CHALLENGING RADIAL CASES How to treat Dr Jim Nolan University Hospital of North Staffordshire Rencontres Interventionnelles - Transradial Approach Prague, Czech Republic, 2011 Wednesday, October 12, 2011
- 2. ISSUES FOR DISCUSSION • Influence of forearm arterial anatomy on procedural outcome • Subclavian issues • Backup issues • Challenging cases Wednesday, October 12, 2011 2
- 3. IN MY PRACTICE I ACQUIRE AN ARM ANGIOGRAM IN ALL PATIENTS AFTER SHEATH INSERTION Wednesday, October 12, 2011 3
- 4. Heart 2009
- 5. ARM ANGIOGRAM • Simple and easy to acquire(3-‐5ml of contrast) • Minimal Vme penalty/radiaVon • Allows operator to plan an opVmal procedure • Reduces risk of complicaVons
- 7. NORMAL ANATOMY • Present in most (86%) paVents • Forearm vessels are usually of good calibre (2.5-‐3.0mm at wrist level) and so will accommodate 6f or larger catheters • Minimal tortuosity reduces risk of spasm • Employ variety of catheter selecVon strategies with expectaVon of procedural success
- 8. VARIANT ANATOMICAL PATTERNS AND PROCEDURAL OUTCOME 8
- 9. WHAT IS THIS ANATOMICAL PATTERN?
- 10. HIGH BIFURCATION WITH AXILLARY ANASTAMOSIS
- 11. HIGH BIFURCATION WITH AXILLARY ANASTAMOSIS
- 12. HOW COMMON IS A HIGH BIFURCATION? (Lo/nolan et al,2009) NORMAL ANATOMY 86% VARIATION 14% High bifurcaVon 7% Loops 2.3% Tortuosity 2% Other variaVons 2.5% FREQUENCY OF HB DOES NOT CHANGE WITH AGE
- 13. DOES VARIANT ANATOMY IMPACT ON PROCEDURAL FAILURE RATE 15.0 14.2 11.3 7.5 3.8 0 0.9 NORMAL VARIANT
- 14. IMPACT OF ANATOMICAL VARIATION (Zhen-‐xian Y et al, Circ J 2010, n=638) PUNCTURE FAILURE RA OCCLUSION 5.0 4.8 7.0 6.3 3.8 5.3 2.5 3.5 2.7 1.3 1.8 0.7 0 0 N V N V
- 15. ANATOMICAL VARIATION AND PROCEDURAL VARIABLES (Bin N et-‐al, Chi Med J 2009, n=3000) DURATION (min) FLUORO TIME (min) 32 32 8.0 31 7.2 29 28 6.0 27 5.6 26 N V 4.0 CONTRAST (min) 60 55 2.0 45 38 30 15 0 0 N V N V
- 16. COMPLICATIONS AND ANATOMICAL VARIATION P<0.001 2.00 1.50 1.30 1.00 PERFORATION 0.50 0 0.04 N V
- 17. ARE ALL ANATOMICAL VARIATIONS OF SIMILAR SIGNIFICANCE? 40 37 30 23 20 13 10 5 0 1 NORMAL HIGH BIFURCATION OTHER ANOMALIES TORTUOSITY LOOPS
- 18. High-‐bifurcaVng radial artery -‐ anastomosis sites and diameters 50% 38% 25% 13% 0% Axilla Upper humerusMid humerusLower humerus 40% 30% 20% 10% 0% <2.0mm 2.0-‐2.5mm 2.5-‐3.0mm >3.0mm
- 19. DIAGNOSTIC CASES minimise catheter size and exchanges-‐ 5F Terumo Tiger catheter
- 21. COMPARISON OF TIGER v JUDKINS
- 22. COMPARISON OF TIGER v JUDKINS
- 23. WHAT ABOUT PCI CASES
- 24. INFERIOR STEMI-‐RCA 1VD(5F TIGER)
- 26. Final result 26
- 28. SHEATHLESS GUIDES COMPARATIVE EXTERNAL DIAMETERS
- 30. STRATEGIES FOR DEALING WITH HIGH BIFURCATIONS • RelaVvely common ( 7%) but benign, frequently unilateral and are not age related • Oken smaller calibre ( 50% less than 2.5mm) • Minimise catheter exchanges ( 5F Tiger catheter for diagnosVc angiography) • Consider 5F guiding catheter for PCI • Consider sheathless guides to minimise radial trauma if 6f needed
- 32. Radial loops 32
- 33. HOW COMMON IS VARIANT ANATOMY NORMAL ANATOMY 86% VARIATION 14% High bifurcaVon 7% Loops 2.3% Tortuosity 2% Other variaVons 2.5 FREQUENCY INCREASES WITH AGE
- 34. ARE ALL ANATOMICAL VARIATIONS OF SIMILAR SIGNIFICANCE 40 37 30 23 20 13 10 5 0 1 NORMAL HIGH BIFURCATION OTHER ANOMALIES TORTUOSITY LOOPS
- 35. RADIAL LOOPS • Occur in around 1/50 paVents • More common in elderly • Developmental anomaly that are related to ageing of the CVS • Oken bilateral • Difficult to overcome even for experienced operators • Spasm is very common when loop is straightened • Consider femoral access ( depending on availability and your experVse level )
- 36. WHAT IS THIS CHARACTERISTIC APPEARANCE ASSOCIATED WITH?
- 38. Anatomy of ROS
- 39. ROS – CD ANGIOGRAM SUBCLAVIAN ARTERY DESCENDING AORTA
- 40. ROS – CT 3D RECONSTRUCTION
- 41. RETROESOPHAGEAL SUBCLAVIAN • More common in women • Associated with chromosomal defects • Usually asymptomaVc • Can cause dysphagia • Rare occurrence of limb ischemia due to thromboVc occlusion • Difficult to manage but rare
- 42. IMPACT OF RETROOESOPHAGEAL SUBCLAVIAN (Bin N et al, Chi Med J 2009, n=3000) • 3 in 3000, incidence rate of 1 in 1000 cases • Procedural failure in 2 out of 3 cases (66% faliure rate)
- 43. IMPACT OF RETROESOPHAGEAL SUBCLAVIAN (CCVI 2001, n=3730) • 3750 consecuVve TRA • 11 with RROS (incidence rate 0.3%, approximately 1 in 400) • Failure in only 1 paVent • Failure due to RROS 0.03% • 1/3500 failures – ie experienced operators can overcome this problem
- 44. RETROESOPHAGEAL SUBCLAVIAN • Rare (1/400) • Challenging • Can be overcome by experienced operators • Very difficult to succeed for inexperienced operators • Consider another access site
- 45. Back up and support issues
- 46. Primary PCI – tortuous RCA 46
- 47. SUPPORT OPTIONS • Standard strategies (addiVonal wire,opVmal lesion preparaVon,opVmised stent strategy) • Select opVmal guide configuraVon ( for RCA in RRA consider AL1, AL0.75 or specific radial curve • Deep incubaVon manoeuvres • Catheter extension systems
- 48. Effect of coronary intubaVon
- 49. GUIDELINER CATHETER EXTENSION SYSTEM
- 51. Guideliner deployed in RCA
- 52. Guideliner – stent deployment
- 53. Final result
- 54. Other opHons for difficult delivery situaHons
- 55. LAD CTO
- 56. LESION WIRED BUT UNDILATABLE
- 57. IC laser for plaque modificaVon
- 58. LASER USE AND TRA • Technically simple device for plaque modificaVon • 6F monorail • Plaque modificaVon,undilatable lesions,thrombus disolouVon
- 65. Complex PCI Case 1
- 66. Case 1 • 78 y/o female • HTN • Prior MI • ACS with widespread ST depression • Cardiogenic shock (SBP 60mmHg)
- 68. 68
- 70. Simutaneous kissing stents (Shot Gun)
- 71. Final result
- 72. Case 2 • 63 y/o • PVD – bilateral femoral by-‐pass • Right radial used as conduit • Previous MI • Severe LV impairment
- 73. Case 2 • Angiogram 3 months previous from LRA • Severe 3VD and LMS (calcified vessels) • Turned down for surgery • IniVally treated medically • Recurrent instability VT / NSTEMI/LVF • MRI – mainly viable myocardium (scar in lateral wall only) • Therefore for PCI to LMS/LAD and RCA
- 75. 0.014 wire to aorta
- 76. 4F sheath
- 77. 6F sheath
- 78. PCI to RCA
- 82. TAKE HOME MESSAGES • Be aware of variant arm arterial paperns • Alter your catheterisaVon strategy in response to the anatomical papern • Tiger catheter has advantages for TR diagnosVcs • Catheter extensions are a good soluVon to backup issues • IC laser is easy to deploy via 6F systems • Sheathless guiding systems facilitate TR PCI when large lumen is needed • Radial access ( employing a full range of available technical innovaVons to opVmise outcomes )can be employed in technically challenging situaVons
- 84. 7.5F PBU3.5
- 86. 1.5mm Rota Burr
- 89. Guideliner case
- 95. EBU 3.56F
- 97. Whisper would not pass – Fielder XT
- 98. • Unable to cross lesion with balloon • SoluVon?
- 99. 0.9mm laser allows passage of 1.1mm balloon