Trans Radial PCI - basic

1. Basics of PCI
through
TRA
Dr. Ashok Dutta
FCPS (Med), MD(Card), FACC
Associate Professor & Senior Consultant
Dept. of Cardiology
NHFH & RI , Dhaka

2. PCI History and TRI

3. Route of Interventions
Radial(Rt. or Lt.), d-RA,Ulnar, Femoral .
Diameter- Radial=2.0-3.0 mm. Femoral= 3-4 times Radial.

4. Basic Steps in PCI
Topic TRA TFA
A. Access ( Gate way to PCI) Difficult but least complications Easier but more complications.
Pathway to Coronary Narrow, multiple struggles, angles Highway, only 1 U-turn.
GC
( platform for PCI)
5,6 &7 F. Manipulation-difficult & painful. 5-9 F. Manipulation-easy and
painless.
Devices-
wire, balloon, stent.
Some restriction with 5-6 F GC. No restriction with 7-8 F. GC
Adjunct Device-
IVUS,OCT, FFR,IFR, Rota.
Same Same
Hemodynamic
( Guiding Star)
Same Same

5. Difficulties in TRI
Difficulties are:
1. Failure to puncture RA. Gateway to PCI.
2. Radial artery spasm,
3. Radial artery loop,
4. Recurrent radial artery,
5. Brachial artery loop/tortuosity,
6. Arteria lusoria,
7. Difficulty in coronary cannulation by GC. Platform for PCI.
8. Difficulties during PCI , more or less like that in TFI.
9. Peri-procedural Complications.
Pathway to PCI

6. Patient Selection
• For the beginner, try to avoid :
 ACS patient.
Multi-vessel and high risk PCI.
High risk patients- poor LV, arhhythmia, other comorbidities.
Short stature, female.
Aortic valve disease.

7. Arterial Puncture
• 2-3 cm or more proximal to styloid process.
• More horizontal than femoral puncture
• Don’t hesitate to puncture deep to posterior wall.
• Then pull back very slowly & more horizontal till free flow
of blood.
• VasoFix cannula, angiocath needle, micropuncture
needle.

8. • Consider the Aortic Anatomy- Diameter, Unfolding of aorta.
• Takeoffs of LCA & RCA.
• Coronary artery Lesions characteristics.
• With 7 F catheter(ID-2.1 mm): most purposes can be served.
• 6 F catheter (ID-1.8mm)- 2 wire, 2 balloon , 2 stents , Rota bar upto 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. NC balloon up to 4 mm negociated if new. 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 .
Guide Cath. Selection
(If you want peace, prepare for War)

9. Cannulation of Coronaries
• Catheter movement is opposite to that of femoral
approach.
• In Femoral approach – movements of hands and in TRI
movements of fingers .
• Be gentle in manipulation of catheter, otherwise artery
will go into spasm. Pain is the first predictor of spasm.
• Frequent catheter change may also produce spasm
• Remove the catheter with regular wire to avoid arterial
wall injury.

10. Short Stature-Small aorta – smaller curve - 3.0.
Dilated ascending aorta- larger Curve – 3.5.
EBU/XB 3.0/3.5, JR-3.5 , AL-1,2,Ikari ,TIG

11. G. Catheter selection- Support
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.

12. Manipulation of AL
Push cath.
With wire up
to aortic sinus
Rotate clockwise
with/without GR
inside
Again push
to engage
RCA Disengagae by
anticlock
rotation &
further pushing

13. Steps of PCI
1. GC engagement.
2. Wiring of the diseased artery.
3.Predilatation (with compliant/non-compliant balloon,
2.0-3.0 mm. Dia X 8.0-15 mm.)
4. Stent deployment.
5. Post Dilatation.
6. Angiographic views.
7. Removal of hard ware and catheter.

14. Wiring and wire selection.
Select a family of wire, you are comfortable with and get enough experience.
Work-horse wire:
Runthrough.
BMW.
Sion.
Sion Blue.
Suoh 03.
Polymer Jacketed Wire
• Fielder FC
• Fielder XT.
• Sion black.
• Pilot 50,200.
• Whisper.
• Stiff wire:
• Gaia
• Conquest/confianza.
• Miracle.
• Support wire
• Grand slam.
• Ironman.
• Mailman.
Standard lesion: workhorse wire. Tortuosity: Suo-03, Fielder FC, whisper.
Non-calcified CTO: Polymer Jacketed, Gia, Pilot 200. Calcified CTO: Stiff wire.

15. Adjunctive devices
• IVUS.
• OCT.
• FFR.
• Aspiration catheter.
• Cutting balloon/angiosculp/NSE.
• Rotablatoer.
• Mother in child
catheter/Guidezilla.

16. Recommended tip curves :
Straight forward procedures ( panels A and B),
More complex anatomies ( panels C –E)
Chronic total occlusion (CTO) ( panel F).

17. Predilatation
• 1.25-2.5 mm X 8-15 mm Compliant balloon. At nominal (12 atm) or
higher pressure to crack the lesion. Shorter NC balloon (2.75X8-
12mm) provides focal pressure and good bed preparation at the cost
of more dissection. Longer balloon less dissection.
• After predilatation IC NO3, then good angio-views and it’s analysis is
essential before stent selection & deployment.
• Stent length and diameter are determined by visual estimation,
measurement of lesion length by floppy segment of the wire, from
balloon length, measuring tool, IVUS,OCT.
• GC- outer diamter = 5-7 F X 0.33 mm. ID= 5-7 F X 0.30 mm.

18. • Compliant balloon: nominal pressure 8 atm.
RBP=18 atm. 20% increase in size.
• Trackability and flexibility is good but
dilatation force is limited.
• NC balloon: nominal pressure-12 atm. RBP- 24 -
28 atm. Increase in size by 5%.
• Semi compliant: increase by 10% with high
pressure.
• Cutting balloon: AngioSculpt Scoring balloon-
having helical, spiral struts ( scoring element).
Flexotome cutting balloon- NCB with longitudinal
3 knives. Useful for ISR and calcified lesion. High
profile, high expense and stiffer .

19. Stent deployment & post dilatation
• After stent positioning, before deployment/inflation, a good view for positioning the
stent from healthy to healthy segment.
• Deploy at nominal pressure, 8-12 atm.
• Post dilatation by same diameter NC balloon, least dilated segment first then all over the
stent at 12-28 atm. Pressure.
• For focal under-expanded segment, short NC balloon dilatation at high pressure 20-28
atm. Give better apposition.
• POT sometimes need ,if there is mismatch of proximal and distal vessel diameter. Distal
diameter should be the referral for stent selection.
• Good post dilatation is the single most independent predictor of short and long term
outcome.
• Complications during post dilatation- Edge dissection, stent deformity/ strut-fracture,
vessel rupture.
• IVUS or OCT – in selected cases.

20. IVUS and OCT
May be needed before stenting and after stenting.
• To assess pre stent lesion characteristics.
• Stent length and diameter determination.
• Stent malapposition.
Specially important in LM stenting , Bifurcation stenting and other
complex coronary intervention ( long, calcified lesion, ISR).

21. Successful PCI-
Defined by angiographic, procedural, and clinical criteria
Angiographic Success: Stented artery with no residual stenosis.
Procedural success : Angiographic success without in-hospital major
complications. (e.g., death, myocardial infarction [MI], emergency
CABG).
 Clinical success: Anatomical and procedural success with
relief of signs & symptoms of myocardial ischemia
after recovery from the procedure.
Long term clinical success: Symptom free for >6 months.

22. Mechanisms of Angioplasty and Stenting
1. Disruption of plaque and the arterial wall : fracture and splitting of
lesion ( Concentric-thinnest & weakest point. Eccentric lesion- at the
junction of plaque & normal wall). Restraining effect caused by lesion is
lost , lumen becomes larger. This is the major mechanism of balloon
angioplasty.
2. Loss of elastic recoil: Balloon dilatation causes stretching and
thinning of the medial wall.
3. Redistribution and compression of plaque components.

23. Complications of PCI
• Air embolism.
• Iatrogenic dissection.
• Stent edge dissection.
• Underexpansion of stent/Malapposition.
• Acute stent thrombosis.
• Coronary perforation/rupture>> c. tamponade.
• SB occlusion.
• Wire fracture.
• Wire, balloon, stent entrapment.
• Death- 0.1%.
• MI-1-3%.
• Urgent CABG- 0.5-2%

24. Tips to prevent Air embolism.
Once GC is inserted in aorta, aspirate it with Y connector locked.
or aspirate first then connect the GC with Y-connector.
Look for back flow/flush to avoid air embolism.
Flush frequently after each device removal, specially bulky one.
Watch the tip of the catheter when withdrawal of the device
especially with ostial & proximal plaques.
During injection, keep the tip of the syringe pointed downward.

25. Patent Hemostasis.
Arterial lumen is patent but flow is maintaining .
C.f.- occlusive.

26. Thank You