Slender Club Japan (SCJ) is an organization that advises Japanese companies on developing slender cardiac devices. They have contributed to the development of the Ikari guiding catheter, 0.010 inch systems, sheathless systems, Glidesheath slender, and a 6F intra-aortic balloon pump (IABP). The presentation discusses the Ikari L guiding catheter concept and its advantages over other catheters for transradial interventions. It also evaluates the feasibility of using a 6F IABP via the brachial artery, finding lower bleeding risks but some limitations like lack of pressure monitoring and limited balloon capacity.

1. Brachial IABP to Support
Complex Transradial PCI and
Slender Club Japan
Yuji Ikari, MD
Department of Cardiology
Tokai University School of Medicine,
Japan
Stuttgart 2017

2. Disclosure conflict of interest
No conflict of interest to declare

3. Slender Club Japan (SCJ)
• SCJ is organized by the Three
Musketeers.
• SCJ has developed new slender
techniques
– Emperor’s new clothes
– Chameleon
• SCJ has advised Japanese
companies to develop new slender
devices.

4. Slender Devices
• Ikari guiding catheter
• 0.010 inch system
• Sheathless system
• Glidesheath slender
• 6F IABP
• And others

5. Now, many types of Ikari L are available.
Terumo
Heartrail2
Asahi Intech
Hyperion
Goodman
Profit
Medtronics
Launcher

6. Ikari L concept
Judkins L easily looses engagement in TRI
Ikari L has stable engagement

7. Hypothesis; physics of backup force
• Fcosq =k(fcosq’ + l)
• fcosq ’ + l
Fmax = k ―――――
cosq
Maximum backup force is
acheved if
q=90 degree; q’= 0
degree; or l is large.
q’ q
l
Ikari et al. J Invasive Cardiol 2005 ;17:636-41

8. Judkins L can generate greater
backup force in TFI than in TRI.
θr
A
θf
B
0
10
20
30
40
50
60
70
TRI TFI
resistance(gramforce)
P<0.05
Ikari et al. J Invasive Cardiol 2005 ;17:636-41

9. Deep engagement increases
backup force in Judkins L
θ4 θ4deep
0
10
20
30
40
50
60
JL4.0 JL4.0 Deep
resistance(gramforce)
P<0.05
Ikari et al. J Invasive Cardiol 2005 ;17:636-41

10. θi
θfθr

11. Ikari L Power Position is not Deep!
11
A B
C D

12. Ikari LPower Position is not Deep!
Safe Procedure

13. TRI for Right Coronary Artery
Amplatz L Ikari L Judkins R Ikari L
With 035 inch GW

14. Angiography by Ikari-L 3.5
6Fr
N = 621
Ad hoc PCI
N =380 (61.2%)
Primary endpoint
Device efficacy
Device safety
Secondary
endpoint
Procedural success
Engagement rate
Procedure time
Fluoroscopy time
Contrast volume
EuroInterv. 2007; 3: 475-481.
Engagement rate
RCA 609(98.1%)
LCA 617(99.4%)

15. STEMI： ST elevation in II, III, aVF
Primary PCI was tried in another hospital

16. They tried TRI using a 6F Amplatz Left 1.
A guidewire passed the lesion but a balloon
could not. They failed PCI despite 3 hours
procedure.
Final

17. The patient transferred to our hospital.
A young doctor successfully performed POBA
using a 7F Ikari L and anchor balloon technique.
TIMI 3 flow was achieved.

18. I performed PCI using a 6F Ikari L without any
techniques such as anchor balloon.
Power position of Ikari L

19. Comparison in TRI
JR IR AL IL
0
20
40
60
80
100
120
140
160
JR4 IR1.5 AL1 IL3.5
maxresistance(gforce)

20. New Concept of Ikari L for STEMI
• TRI for STEMI Improves
Mortality
• Shorter D2B time is
necessary
• If Ikari L is used you can
shorten reperfusion time

21. Primary PCI for STEMI
1) Radial artery puncture
2) Insertion of diagnostic catheter (L)
3) Engagement of diagnostic catheter (L) for LCA
4) Angiography of LCA
5) Removal of the catheter (L)
6) Insertion of diagnostic catheter (R)
7) Engagmennt of diagnostic catheter (R) for RCA
8) Angiography of RCA
9) Removal of the catheter (R)
10) Insertion of a guiding catheter
11) Engagement of the guiding catheter
12) Guidewire passage
13) First device activation (balloon or thrombus aspiration)＝Reperfusion
Catheter insertion 3 → 1
Catheter removal 2 → 0
Engagement 3 → 2

22. Puncture to Balloon time
10 (7-12)min 17 (13-23) min
p=0.001
IL
group
Conventional
group
min
Cardiovasc Interv and Ther
DOI 10.1007/s12928-016-0395-z

23. Tip Entry Profile: 0.014-inch 0.012-inch
（0.36 mm 0.31 mm）
OLD NEW
0.0120.014
0.010

24. Ikazuchi X balloon
Possible to insert
2 balloons and 2 wires
together within the
5Fr guiding catheter
3 balloons and 3 wires
together within the
6Fr guiding catheter

25. 5Fr KBT
Yoshimachi F, Masutani M, Matsukage T, et al.
J Invasive Cardiol 2007;19:519–524
6Fr KGT
Matsukage T, Masuda N, Ikari Y
J Invasive Cardiol 2008;20:E210–214
Available in the Small-lumen Guiding Catheter

26. Initial IKAZUCHI-X crossing 147 / 147 (100)
Requirement of 0.014-inch guidewire 9 / 148 (6.1)
To pass a CTO lesion 1
To deliver a STENT system 8
Clinical success (for cases) 132 / 133 (99.2)
Device success (for lesions) 147 / 148 (99.3)
Registry study for routine use of 0.010 system
Including 25 CTO lesions
A 010 Balloon is good.
However, there is a limitation in 010 guidewires.

27. 3 Fr Sheath O.D. Sheathless 5 Fr G.C
1.70 mm 1.71 mm
3 5
0.059 inch 0.059 inch
≒
A 5F Guiding catheter is used without a sheath,
It is equal to 3F sheath size.

28. 0.025-inch Guidewire
: Central Dilator
5Fr. IKARI Guiding Catheter

29. Medikit
iWorks virtual 3F
Terumo Heartrail2
IFL

30. Target lesions: Mid LAD & Mid RCA

31. STENT
Cypher 3.0 x 23mm: 16atm
Two stents were implanted using 010 GWs

32. Kissing Balloon Technique

33. Final Angiography of LAD

34. IL4.0 : 5Fr
Guiding Catheter

35. STENT
Cypher 3.0 x 28mm: 16 atm

36. ↑18G TERUMO NEEDLE (1.20mm)
↑３F Ikari left (1.17mm)
Virtual 1F
Sheathless 3F diagnositic angio
Ijichi et al. Catheter Cardiovasc Interv 2013;82:E676

37. CAG LCA
Virtual 1Fr

38. Virtual 1 Fr
CAG RCA

39. Virtual 1F=19G needle size
Terumo gave up sales because manufacturing
cost was higher than sales cost

40. Thinner sheath wall thickness to
make outer diameter smaller
＊Intended to use only radial approach
Design Concept

41. 3 size variation to improve daily TRI practice
5Fr
Less invasiveness
6Fr
Daily Practice
7Fr
Complex PCI
Size variation

42. Slender IABP
• 6F IABP system (Zeon Medical)
• Compatible GW is 0.014 inch
– Impossible to monitor arterial pressure
• Only 30 ml type
• Catheter length is short
– 777mm
0.017inch

43. 6Fr IABP
via Lt. Brachial
Trans-Brachial IABP insertion Method

44. Pressure wave pattern of
the guiding catheter
6Fr IABP
via Lt. Brachial
Trans-Brachial IABP insertion Method

45. IABP Remove & Hemostasis
Removing with a brachial compression device (Tometa-kun™).

46. Fujii T, Masuda N, et al. J Invasive Cardiol. 2012 Dec;24(12):641-4.

47. 42 elective PCI cases
with a prophylactic
IABP assistance
6Fr TB-IABP (n=15)
6Fr TF-IABP(n=5)
8Fr TF-IABP(n=22)

48. Procedural Characteristics
6Fr-IABP 8Fr-IABP P-value
(n=20) (n=22)
GC Size (Fr) 6.1±0.5 6.6±0.8 0.011
IABP Volume (ml) 30.0±0.0 35.4±5.7 <0.001
Numbers of Stent 2.1±1.2 1.8±1.0 0.927
Procedural Time (min) 141.9±56.6 108.1±60.7 0.092
Fluoroscopy Time (min) 42.9±24.7 28.7±19.9 0.055
IABP Actuation Time (min) 127.1±59.2 87.9±52.3 0.044
Contrast Volume (ml) 246.9±106.2 223.8±95.2 0.479
Total Heparin (units) 8277.8±1564.5 7617.6±1798.7 0.254

49. 6Fr TB-IABP 6Fr TF-IABP 8Fr TF-IABP
P-value
(n=15) (n=5) (n=22)
IABP access site complications 0 0 3 (13.6%) 0.243
In-hospital MACCE 0 0 0 N/A
In-hospital Death 0 0 0 N/A
ΔHemoglobin (g/dl) -0.8±0.9 -1.2±1.9 -1.5±0.9 0.137
ΔHematocrit (%) -2.5±3.0 -4.7±5.3 -4.3±3.0 <0.001
ΔPletelet (×104/µl) -1.3±2.2 -4.3±3.9 -1.7±2.1 <0.001
Bed Rest Time after PCI (min) 0.0±0.0 288.0±107.3 360.0±104.7 <0.001
In-hospital Stay after PCI (days)
1.0
(1.0-2.0)
5.0
(3.0-8.0)
2.0
(1.0-5.0)
0.007
Defer the Discharge for Bleeding
Complications
0 0 3 (13.6%) 0.243
Re-hospitalization for Bleeding
Complications
0 0 1 (4.5%) 0.646
Results

50. Limitations (Device)
 Guidewire 0.014 compatible
Balloon volume is ONLY 30ml.
 IABP tip pressure is NOT available.
 Trans-Brachial insertion is Off Label use.
In case of draw-back of the IABP catheter,
it may cause injury on subclavian artery.

51. Limitations (Patients)
Not applicable to patients with so-called
type III arch.
⇒Checking the arch anatomy is important
for safe TB-IABP.

52. Summary : 6F IABP
The 6-Fr IABP system was feasible in
clinical use with lower bleeding
complications.
However, TB-IABP has several critical
limitations such as no blood pressure
monitoring, potential risk for subclavian
artery or more time necessary for the
procedure due to less support of 0.014
inch GW.

53. Slender Club Japan has advised Japanese
companies on development of slender
devices
• Ikari guiding catheter
• 0.010 inch system
• Sheathless system
• Glidesheath slender
• 6F IABP
We had our ups and downs.

54. Slender Club Japan
http://www.cardiologist.jp/ptca5fr/scj.htm