1. The document discusses the basics of percutaneous coronary intervention (PCI) through the transradial approach. It covers the history, access routes, procedural steps, guide catheter selection, complications and tips for successful PCI. 2. Key points include that the radial approach has a narrow pathway but fewer complications compared to the femoral approach. Guide catheter size selection depends on the vessel diameter and intended devices. Wiring, balloon angioplasty, stenting and post-dilatation are the standard steps of PCI. 3. Complications include dissection, perforation and stent malapposition. Tips provided to prevent complications and ensure procedural success include proper guide catheter and device selection, gentle manipulation, and frequent

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