New sheathless technique - Mamas Mamas

1.
New sheathless V3Fr technique
Mamas Mamas
Professor of Cardiology
Keele Cardiovascular Research Group
Keele University, UK
#RadialFirst

2. Conflict of interest
• I have no conflict of interest to declare
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3. Radial Injury: Sheath to RA ratio
Radial Injury / Radial occlusion
Sheath < Artery diameter Sheath > Artery diameter
Yonetsu et al EHJ 2010

4. Reduce the mismatch between vessel
size and catheter

5. Background
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6. Background
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7. Background
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12. Failure of adoption to widespread
practice
• Unfamiliarity with catheters
- Shapes
- Performance / stiffness
• Main utility large bore (only recently 5Fr available)
• Lack of a total solution: current catheters only useful for
elective cases with known anatomy.. No diagnostic catheters
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13. #RadialFirst

14. Modified BAT Sheathless technique
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15. Balloon assisted tracking
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16. Advantages
• Total sheathless solution, diagnostic and guide, any
catheter manufacturer
• Easy ability to upsize (many sheathless systems need
dedicated dilator so more costly)
• No transition zone between guide / wire: Minimise
razor effect, less radial injury
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17. Tips and tricks
• Use Terumo Radifocus Optitorque Tiger catheter for
diagnostic procedures (ID 1.20mm). Other diagnostics such as
Boston Expo ID too small (ID 1.10mm) if Rx balloon used.
• JL shape difficult to deliver with this technique. (Use EBU
guide if Tiger fails)
• If other makes of diagnostic with smaller ID, OTW balloon
can be used so all 5Fr catheters compatible.
• Low inflation of balloon (6 Atm)
• 1.5mm balloon can also be used, shaft more easily damaged
with multiple exchanges
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18. • Use 0.035” wire once catheter reaches subclavian. In tortuous
anatomy where catheter needs to be torque a lot to cannulate,
proximal end of diagnostics can knot at wrist.
• Technique allows upsizing to 6Fr or 7Fr, Successfully used in
8Fr
• TR band can be removed within 30 minutes.
Tips and tricks
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19. Patient characteristics
270 V3 Fr consecutive cases
Number of patients
270
Age (mean ± SD)
64.3 ± 11.1 years
Sex
Male 194 (71.9%)
Female 76 (28.2%)
Ethnicity
Caucasian 265 (98.2%)
Asian 5 (1.9%)
Coronary risk factors
Diabetes 45 (16.7 %)
Hypertension 156 (57.8%)
Hypercholesterolemia 111 (41.1%)
Previous PCI
38 (14.1%)
Previous CABG
13 (4.8%)
Smoker
41 (15.2%)
Family history of ischaemic heart
disease*
55 (20.4%)

20. Indication for procedure
Elective (n=109, 40.4%)
ACS (n=111, 41.1%)
STEMI (n=35, 13.0%)
Other (n=15, 5.6%)
Access site
Right radial 254 (94%)
Left radial 14 (5.2%)
Both 2 (0.7%)
Procedure
Angiogram only 132 (48.9%)
Angiogram and PCI 137 (50.7%)
Pressure wire 1 (0.4%)
Number of catheters used (mean ± SD)
1 (n=139, 51.7%)
2 (n=107, 39.8%)
3 (n=21, 7.8%)
4 (n=2, 0.7%)
Catheters used
Tiger (n=207, 76.7%)
EBU (n=105, 38.9%)
Judkins Left (n=17, 6.3%)
Judkins Right (n=62, 23.0%)
Ikari (n=5, 1.9%)
DC3 (n=2, 0.7%)
Amplatz (n=2, 0.7%)
Radiation dose (mean ± SD)
3122.2 ± 3172.1
Fluoroscopy time (mean ± SD)
8.0 ± 6.7 min
Success rate
Successful 252 (95.1%)
Unsuccessful 13 (4.9%)

21. Failures: 4.8%
• Initial learning curve: tortuous subclavian,
kinking catheters
• Radial spasm due to excessive catheter
manipulations
• Poor backup support
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22. Conclusions
• Technique allows switch to total sheathless practice
• Technique feasible with 95% success rate in 270
cases, can reduce radial compression times to 30
minutes.
• Allows flexibility, upsizing to 6Fr / 7Fr easy
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