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Kirtane AJ 2013 06

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Ad hoc PCI via the transradial approach: how to achieve success

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Kirtane AJ 2013 06

  1. 1. Ajay J. Kirtane, MD, SMAjay J. Kirtane, MD, SM CenterCenter for Interventional Vascular Therapyfor Interventional Vascular Therapy Columbia University Medical Center /Columbia University Medical Center / New York Presbyterian HospitalNew York Presbyterian Hospital Ad Hoc PCI via theAd Hoc PCI via the Transradial Approach:Transradial Approach: How to Achieve SuccessHow to Achieve Success
  2. 2. ConflictConflict of Interest Disclosureof Interest Disclosure •• Ajay J. KirtaneAjay J. Kirtane ¡¡ NoneNone ¡¡ Off-label use will be discussedOff-label use will be discussed
  3. 3. Basic Principles of Transradial PCI:Basic Principles of Transradial PCI: Debunking the MythsDebunking the Myths •• Back to basics: standard and essential PCIBack to basics: standard and essential PCI principles apply!principles apply! •• Pre-cath evaluationPre-cath evaluation ¡¡ Evaluate the hand and pulses (all) yourselfEvaluate the hand and pulses (all) yourself •• In-lab procedureIn-lab procedure ¡¡ PCI success depends on ability to access thePCI success depends on ability to access the artery selectively, cross with wire, and deliverartery selectively, cross with wire, and deliver devices, which is dependent upon support ofdevices, which is dependent upon support of the guide/wire (coaxial system)the guide/wire (coaxial system) •• Post-cath access / carePost-cath access / care
  4. 4. Setup / Operator / Lab ComfortSetup / Operator / Lab Comfort Radial site R Groin site
  5. 5. Basic Principles of Transradial PCI:Basic Principles of Transradial PCI: Debunking the MythsDebunking the Myths •• Hemodynamic assessments are possible!Hemodynamic assessments are possible! ¡¡ LV can be accessedLV can be accessed •• Wire-facilitated catheter crossingWire-facilitated catheter crossing •• Stiffer diagnostic catheters can helpStiffer diagnostic catheters can help ¡¡ RHC can be performed from the armRHC can be performed from the arm •• Brachial vein approach with 5 FrenchBrachial vein approach with 5 French SwanSwan ¡¡ Venous sheath in neck or groinVenous sheath in neck or groin
  6. 6. How to do a RHC from the ArmHow to do a RHC from the Arm •• Brachial vein accessBrachial vein access ¡¡ Re-wire existing antecubital i.v.Re-wire existing antecubital i.v. ¡¡ Insert new iv/sheathInsert new iv/sheath ¡¡ Ultrasound-guided brachial vein accessUltrasound-guided brachial vein access •• 5 French Swan-Ganz Catheter5 French Swan-Ganz Catheter •• BMW or workhorse wire (to direct the swanBMW or workhorse wire (to direct the swan through smaller arm vessels)through smaller arm vessels) •• 14 Guage Angiocath to exchange for sheath14 Guage Angiocath to exchange for sheath at end of caseat end of case
  7. 7. Exchanging antecubital i.v. for SheathExchanging antecubital i.v. for Sheath
  8. 8. Antecubital Vein AnatomyAntecubital Vein Anatomy
  9. 9. Try to Avoid the Cephalic (Lateral AC Access)Try to Avoid the Cephalic (Lateral AC Access)
  10. 10. Glidesheath Dilator into 14 Gauge AngiocathGlidesheath Dilator into 14 Gauge Angiocath
  11. 11. After sheath removed over 0.021” wireAfter sheath removed over 0.021” wire
  12. 12. Upfront Choice #1Upfront Choice #1 Radial sheath size: 6 French vs. SmallerRadial sheath size: 6 French vs. Smaller 6 Fr Standard Sheath 0.038” wire 6 Fr Glidesheath 0.021” wire 5 Fr Glidesheath 0.021” wire
  13. 13. Upfront Choice #1Upfront Choice #1 Radial sheath sizeRadial sheath size •• Things you can do with a 6 French Guide:Things you can do with a 6 French Guide: ¡¡ Multiple wire casesMultiple wire cases ¡¡ IVUS / FFR / OCTIVUS / FFR / OCT ¡¡ Bifurcation lesions including kissing balloonsBifurcation lesions including kissing balloons (as long as balloons are not BOTH 3.5-4.0 NC)(as long as balloons are not BOTH 3.5-4.0 NC) ¡¡ Guideliner casesGuideliner cases ¡¡ Thrombectomy cases (but 2Thrombectomy cases (but 2ndnd wire might not bewire might not be possible)possible) ¡¡ Rotational atherectomy (1.25, 1.5 mm burrs)Rotational atherectomy (1.25, 1.5 mm burrs) ¡¡ Embolic protectionEmbolic protection 5 French too
  14. 14. Going from 5 French to 6 French:Going from 5 French to 6 French: How to Upsize a Tapered Hydrophilic SheathHow to Upsize a Tapered Hydrophilic Sheath (0.035” exchange kit exists and Slender sheath coming 7/13)
  15. 15. Down Sizing Equivalent Diameter6Fr GSS6Fr Sheath 5Fr Sheath Gray on strain relief (Indicates O.D. of 5Fr) Green on valve and dilator (Indicates I.D. of 6Fr) Thin-walled Sheath (Slender)Thin-walled Sheath (Slender)
  16. 16. Radial PharmacologyRadial Pharmacology •• Preloading withPreloading with antiplatelet agentsantiplatelet agents ¡¡ AspirinAspirin ¡¡ P2Y12 inhibitorP2Y12 inhibitor •• AnticoagulantAnticoagulant ¡¡ HeparinHeparin ¡¡ BivalirudinBivalirudin ¡¡ Can do radial casesCan do radial cases on therapeutic oralon therapeutic oral agents!!agents!! •• Agents for spasmAgents for spasm ¡¡ Sedation!Sedation! ¡¡ Topical (not i.a.) lidocaineTopical (not i.a.) lidocaine ¡¡ Topical or sq NTGTopical or sq NTG ¡¡ Calcium Channel blockerCalcium Channel blocker •• Nicardipine 200 mcgNicardipine 200 mcg •• Verapamil 250-500 mcgVerapamil 250-500 mcg ¡¡ NTG 200NTG 200-400 mcg-400 mcg
  17. 17. Administering the Radial CocktailAdministering the Radial Cocktail
  18. 18. Wire for Traversing the ArmWire for Traversing the Arm Rosen Standard J •• Standard Approach:Standard Approach: ¡¡ Exchange Rosen WireExchange Rosen Wire ¡¡ Also “Baby J”Also “Baby J” •• For tortuous anatomy:For tortuous anatomy: ¡¡ BMW or non-hydrophilicBMW or non-hydrophilic workhorse wireworkhorse wire •• (Glidewires)(Glidewires)
  19. 19. Navigating Tortuous AnatomyNavigating Tortuous Anatomy
  20. 20. Getting the Guide to the AortaGetting the Guide to the Aorta Patel, Shah, Pancholy, CCI 2013 Balloon-assisted tracking of the guide catheter (to minimize the effect of the guide-wire transition point)
  21. 21. What Guides Should I Use forWhat Guides Should I Use for Transradial PCI?Transradial PCI? •• Start with guides you are familiar with:Start with guides you are familiar with: •• Left Coronary Artery:Left Coronary Artery: ¡¡ EBU 3.5, XB 3.5EBU 3.5, XB 3.5 •• Right Coronary Artery:Right Coronary Artery: ¡¡ JR4, Hockeystick, AL 0.75 or AL 1JR4, Hockeystick, AL 0.75 or AL 1 ¡¡ Typically with sideholesTypically with sideholes •• You can experiement with specialty guides,You can experiement with specialty guides, but these are not a necessitybut these are not a necessity
  22. 22. Specialty Guide ShapesSpecialty Guide Shapes Ikari and Tig “Easy Radial”
  23. 23. Getting the Guide to the Ascending Aorta:Getting the Guide to the Ascending Aorta: Effect of a Deep BreathEffect of a Deep Breath
  24. 24. Engagement: The Wire is Your FriendEngagement: The Wire is Your Friend
  25. 25. “Flipping Down” the Guide“Flipping Down” the Guide
  26. 26. Finding the Left CuspFinding the Left Cusp
  27. 27. Left Guide AdventuresLeft Guide Adventures
  28. 28. Common Myth:Common Myth: Complex PCI Can’tComplex PCI Can’t Be Done RadiallyBe Done Radially
  29. 29. 1.5 mm Rotational Atherectomy1.5 mm Rotational Atherectomy
  30. 30. Guideliner case (Difficult RCA)Guideliner case (Difficult RCA)
  31. 31. Stent with Multiple Wires (jailed wires)Stent with Multiple Wires (jailed wires)
  32. 32. Implications of Radial sheath sizesImplications of Radial sheath sizes •• When do youWhen do you reallyreally need a guide bigger thanneed a guide bigger than 6 French?6 French? ¡¡ *Perforation to facilitate placement of a Jo-*Perforation to facilitate placement of a Jo- Med Graftmaster StentMed Graftmaster Stent ¡¡ Simultaneous 2 or 3 stent case that can’t beSimultaneous 2 or 3 stent case that can’t be done sequentiallydone sequentially •• Minicrush, SKSMinicrush, SKS ¡¡ IVUS-guided CTOIVUS-guided CTO ¡¡ Lost device retrievalLost device retrieval ¡¡ Lack of supportLack of support
  33. 33. Can you use guides bigger than 6 French inCan you use guides bigger than 6 French in the Radial Artery?the Radial Artery? •• Yes!Yes! •• Men: most can tolerate 7 Fr, some even 8 FrMen: most can tolerate 7 Fr, some even 8 Fr •• Women: some can tolerate 7 FrWomen: some can tolerate 7 Fr ¡¡ But radial artery occlusion may become anBut radial artery occlusion may become an issue with either of these approachesissue with either of these approaches •• Sheathless guide techniquesSheathless guide techniques
  34. 34. Sheathless Guide Technique (7 French)Sheathless Guide Technique (7 French) •• Using 5 Fr Dilator orUsing 5 Fr Dilator or long multipurposelong multipurpose diagnostic for thediagnostic for the transition pointtransition point T. Kwan et al, CCI 2012
  35. 35. ConclusionsConclusions •• Basic principles: a PCI is a PCI, and accessBasic principles: a PCI is a PCI, and access is just a part of the caseis just a part of the case •• Knowing just a few basic techniques willKnowing just a few basic techniques will dramatically impact your learning curvedramatically impact your learning curve •• Transradial PCI is not only doable, but inTransradial PCI is not only doable, but in many cases preferred, especiallymany cases preferred, especially ad hocad hoc •• My advice: start with minimal changes toMy advice: start with minimal changes to equipment (use what’s familiar to you) andequipment (use what’s familiar to you) and then start to try other equipment once you’vethen start to try other equipment once you’ve mastered the basicsmastered the basics Ajay J. Kirtane: akirtane@columbia.edu

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