This document describes a novel "parallel sheath technique" for overcoming severe iliac artery tortuosity during catheterization procedures. It presents 5 case examples where the technique was used successfully. The technique involves inserting a second sheath parallel to the first, with an extra-stiff guidewire to straighten the artery. This significantly improves catheter maneuverability through the first sheath. The technique provides an alternative to workarounds like larger sheaths or switching access sites when standard techniques cannot overcome extreme kinking.

1. DR. JUAN CARLOS BECERRA MARTÍNEZ
SERVICIO DE HEMODINÁMICA
UMAE HE CMNO
GUADALAJARA, MÉXICO
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2. Nicolaus Reifart:
Director of the Main Taunus Heart Institute in Bad
Soden, Germany.
Chief of the Departments of Cardiology at the Red
Cross Hospital and Heart Center in Frankfurt until
1997
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3. Introduction
In some elderly patients catheter
manipulation via the femoral approach:
Is barred by a high level of friction due to
severe kinking of the iliac artery
(atherosclerotic vessel remodelling)
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4. Introduction
Common solution:
To use a larger, rigid, kink-resistant long
sheath with a stiff guidewire.
Nevertheless, in rare cases the kinking
cannot be overcome
○ Puncture the contralateral side
○ Switch to the transradial approach
But… the atherosclerotic disease is often
generalized  might also be extremely
difficult
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5. Indications for Use
Severe tortuosity of the access arteries that
prevent acceptable manoeuvrability of
catheters
It will dramatically reduce friction
We do not recommend using closing devices
after the end of the procedure.
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6. Tips & Tricks
Keep a catheter and a stiff 0.035” wire in
the first sheath
Puncture 1-2 mm medially (sometimes
laterally) aiming towards the palpable
sheath
It appears appropriate to use a 4 Fr sheath
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7. Five Cases
The common bail-out technique for all
cases was parallel sheath technique
Two extra-stiff 0.035” wires
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8. Case 1
79-year-old male
80% stenosis of the right common carotid
artery
The 5 Fr dx catheter (right groin) didn’t
advance although we used a long kink-
resistant 8Fr 45cm sheath and a 0.035’’ extra-
stiff guidewire
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9. Case 1
Switch to left groin  Failed too
Right side again:
Second long 5 Fr 45 cm sheath parallel to the 8 Fr
sheath
Advanced a stiff 0.035’’ guidewire via the 5Fr
sheath, nicely straightening the artery.
The common carotid artery was then successfully
dilated and stented.
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10. ©2014EuroIntervention.Allrightsreserved.
EuroIntervention 2014;10:231-235
The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve
catheter manoeuvrability

11. Case 2
73-year-old male
3-vessel coronary artery disease & CABG 17
years ago. Angina pectoris CCS IV
In spite of severe iliac kinking:
Dx angiography with 5 Fr catheters was achieved
using the right groin, a kink-resistant long 5Fr
sheath and a 0.035’’ extra-stiff guidewire
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12. Case 2
Dx angiography :
50% stenosis of the LM
80% lesion of the proximal LAD
Occlusions of the RCA and LCX
Bypass grafts to RCA, CX and LAD were
occluded.
Planned approach:
PCI of LAD
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13. Case 2
The 5 Fr sheath was exchanged for a 7Fr
45cm kink-resistant sheath (Figure 2A), but
the guiding catheter could not be advanced
We inserted a second 5 Fr 45cm sheath
parallel to the 7 Fr sheath
The vessel was straightened (Figure 2B) and
we completed the via the 7 Fr sheath
Eurointervention 2014;10:231-235

14. ©2014EuroIntervention.Allrightsreserved.
EuroIntervention 2014;10:231-235
The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve
catheter manoeuvrability

15. Case 3
71-year-old male with hip dysplasia (pre-operative)
EKG and ECO suggested ischemia.
Coronary angiography was impossible because of
serious elongation and kinking of the iliac artery (Figure
3A), with the 5Fr 45cm sheath
We inserted a second long 5Fr 45cm sheath (Figure 3B)
Two-vessel disease with no indication for PCI.
Eurointervention 2014;10:231-235

16. ©2014EuroIntervention.Allrightsreserved.
EuroIntervention 2014;10:231-235
The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve
catheter manoeuvrability

17. Case 4
75-year-old male
3-vessel disease & CABG 14 years ago
Dyspnoea NYHA Class II.
Due to massive whorls of the artery and
severe friction it was impossible to
manoeuvre the catheter (Figure 4A).
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18. Case 4
Angiography was performed easily only
after parallel insertion of two 45cm kink-
resistant Arrow sheaths (5 Fr and 6 Fr)
(Figure 4B)
Prognostically relevant progression of the
coronary artery disease was ruled out.
Eurointervention 2014;10:231-235

19. ©2014EuroIntervention.Allrightsreserved.
EuroIntervention 2014;10:231-235
The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve
catheter manoeuvrability

20. Case 5
74-year-old male
Symptomatic obstruction of the right
superficial femoral artery.
A crossover manoeuvre via the left groin was
impossible because of severe kinking of the
ipsilateral iliac artery in spite of a kink-
resistant 7Fr sheath and extra-stiff 0.035’’
guidewire
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21. Case 5
Only after inserting a second 4 Fr sheath
with a second stiff 0.035’’ guidewire (Back-
up Meier; Boston Scientific) stenting of the
SFA successful.
Eurointervention 2014;10:231-235

22. ©2014EuroIntervention.Allrightsreserved.
EuroIntervention 2014;10:231-235
The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve
catheter manoeuvrability

23. Conclusions
In all cases the sheaths were removed
immediately and the groin compressed
manually, without any bleeding complications.
In the presence of severe tortuosity of the
femoral or iliac arteries, the insertion of a
second arterial sheath parallel to the first with
an extra-stiff wire will considerably ease
manipulation via the first sheath.
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24. Discussion
This is the first report of a simple and novel
parallel sheath technique to improve
steerability markedly in situations of
insuperable femoral or iliac kinking.
Other possible solutions:
Alternative access
Bigger sheath size
Small sheath into a big sheath
Dental floss technique
○ Not suitable for coronary interventions
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Do not reduce friction

25. Discussion
The parallel sheath technique has been
applied by Dr. Reifart since 2006 in more
than 500 cases of CTO (7 Fr and 5 Fr or 6
Fr) for contralateral injection or retrograde
recanalisation approach.
Major in-hospital bleeding: <1%
Eurointervention 2014;10:231-235