Segev A

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What is Available for Transradial Access

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Segev A

  1. 1. What s Available for Trans- Radial Access Amit Segev, MD, FESC Interventional Cardiology Chaim Sheba Medical CenterSheba Medical CenterTel Hashomer The Leviev Heart Center
  2. 2. Anatomy Radial Artery Ulnar Artery Palmar ArchSheba Medical CenterTel Hashomer The Leviev Heart Center
  3. 3. Allen s testSheba Medical CenterTel Hashomer The Leviev Heart Center
  4. 4. Interpretation of Allen sSheba Medical CenterTel Hashomer The Leviev Heart Center
  5. 5. Assessment of ulnar arch by oxymetry n Allen’s test is subjective and difficult to interpret n Barbeau score 2  min  Sheba Medical Center Barbeau.  G  et  al;  Am  Heart  J  2004;147:489–93  Tel Hashomer The Leviev Heart Center
  6. 6. Barbeau score NO  Sheba Medical Center Barbeau.  G  et  al;  Am  Heart  J  2004;147:489–93  Tel Hashomer The Leviev Heart Center
  7. 7. Room SetupSheba Medical CenterTel Hashomer The Leviev Heart Center
  8. 8. Immobilizing wristSheba Medical CenterTel Hashomer The Leviev Heart Center
  9. 9. Access Anatomic LimitationsSheba Medical CenterTel Hashomer The Leviev Heart Center
  10. 10. RADIAL ACCESS Micro Puncture kit Hydrophilic SheathSheba Medical CenterTel Hashomer The Leviev Heart Center
  11. 11. Radial Spasm n  Prevention n Sedation / Nitro / Verapamil n Hydrophilic-coated sheath and catheter n  Treatment n Nitro / sedation / verapamil / Time… 8 minutes laterSheba Medical CenterTel Hashomer The Leviev Heart Center
  12. 12. Terumo WireSheba Medical CenterTel Hashomer The Leviev Heart Center
  13. 13. Anatomic variations n  23 % of 2 211 radial procedures n  Tortuosity: n  3.8 % n  98.8 % of success rate of the procedure n  Stenotic radial artery n  1.7 % n  91.9 % of success rate of the procedure n  Hypoplastic radial artery n  7.7 % n  93.9 % success rate n  Radio-ulnar loop/radial reccurent artery n  0.8 % n  83.3 % success rate Catheterization and Cardiovascular Interventions 67:870–878 (2006)Sheba Medical CenterTel Hashomer The Leviev Heart Center
  14. 14. Radial/Brachial loopn Terumo GWn Coronary 0.014 wiren Straightened the brachial loop with 4-5-6 F cathetern Long exchange wires Catheterization and Cardiovascular Interventions 68:260–262 (2006)Sheba Medical CenterTel Hashomer The Leviev Heart Center
  15. 15. Tortuous Subclavian / Innominate artery n  Deep breath to lower the heart n  Terumo wire n  Coronary wire n  Straighten Subclavian by placing stiff wire n  Long sheathSheba Medical CenterTel Hashomer The Leviev Heart Center
  16. 16. Understanding the Catheter s Course Right Radial Left Radial Femoral 2 points of 1 point of 1 point of resistance resistance resistanceSheba Medical CenterTel Hashomer The Leviev Heart Center
  17. 17. TRA: Mechanisms of Failure Total number of Failures 98/2100 (4.6%) Failure of arterial access Inadequate arterial puncture 13% Failure to advance catheter to ascending aorta Radial artery spasm 34% HYDROPHYLIC SHEATHS NOT USED Radial artery dissection 10% Radial artery loop/tortuosity 6% Radial artery stenosis 1% Failure to complete PCI due to lack of guide support Subclavian tortuosity 18% Inadequate guide backup support 17% n=2,100 Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064Sheba Medical CenterTel Hashomer The Leviev Heart Center
  18. 18. Catheter selection – why Standard femoral Dx catheters may be used as well as several other universal curves •  Learning curve •  Single vs. Double catheter technique –  Judkins: JL3.5 and JR4 or 5 (XB??) –  Single catheters: •  Jacky, Tiger, Sarah, Kimny, Fajadet •  TRA PCI –  Right: JR4 or 5 – Left: EBU 3.5 / XB3.0 –  Single Catheter Technique: Ikari LSheba Medical CenterTel Hashomer The Leviev Heart Center
  19. 19. Catheter Selection: Femoral vs Radial Radial access requires the use of finger-based torque movements instead of 
 the wrist-based used in femoral access •  Catheter Manipulation Technique –  Transradial approach can involve more tortuosity than the femoral approach –  TRA necessitating small (finger-based) clockwise and counterclockwise torquing movements and active catheter holding as there may be multiple friction points in the subclavian and the aorta JL 3.5 Radial JL 4.0 Femoral Different curve mechanics, 
Sheba Medical Center sizing and backup supportTel Hashomer The Leviev Heart Center
  20. 20. Transradial Curves for Left Coronary – Judkins Left Standard curve for the left coronary artery (may be particularly useful for short left coronary arteries) Sizing suggestions:Downsize the curve by 0.5 from what is used 
 Judkins engagement technique, similar to for a femoral approach femoral approach. Very fine torquing movements may be required to direct the catheter toward the left coronary artery Sheba Medical Center Tel Hashomer The Leviev Heart Center
  21. 21. Transradial Curves for Left Coronary – Extra BackupWorkhorse curve for left coronary artery Sizing suggestions: JL3.5 = EBU3.5 / XB3 JL4.0 = EBU3.75 Comparable to: Cordis: XB, XBLAD BSC: Muta Left, Radial Curve, Brachial CurveSheba Medical CenterTel Hashomer The Leviev Heart Center
  22. 22. Transradial Curves for Left Coronary – EBU/XBSheba Medical CenterTel Hashomer The Leviev Heart Center
  23. 23. Single Catheter Solutions for Diagnostic Catheterization Terumo s Optitorque Diagnostic CatheterAvailable in 5F and 6F Amplatz shape tip Tiger Jacky Rarely coaxial, good for Amplatz type tip (to address RCA, the tip tends to engagement issues), better point superior suited for LVSheba Medical CenterTel Hashomer The Leviev Heart Center
  24. 24. Jacky Catheter: Selective Engagement of RCA and LMSheba Medical CenterTel Hashomer The Leviev Heart Center
  25. 25. IKARI Left CatheterSheba Medical CenterTel Hashomer The Leviev Heart Center
  26. 26. IKARI Catheter vs. Standard Catheters Ikari Y, et. al. Journal of Invasive Cardiology 2005Sheba Medical CenterTel Hashomer The Leviev Heart Center
  27. 27. IKARI Left Catheter: Multivessel InterventionSheba Medical CenterTel Hashomer The Leviev Heart Center
  28. 28. Transradial Curves for Right Coronary – Judkins RightStandard curve for right coronary artery (may be particularly useful for inferior takeoffs) Sizing suggestions: Same as femoral approach Comparable to: Judkins engagement technique, similar to femoral approach. Apply a clockwise Cordis: Judkins Right rotation to engage right coronary artery BSC: Judkins RightSheba Medical CenterTel Hashomer The Leviev Heart Center
  29. 29. Transradial Curves for Right Coronary – Judkins Right Deep intubation of RCA with JR4Sheba Medical CenterTel Hashomer The Leviev Heart Center
  30. 30. Considerations for Using 5F Guide Catheters •  Miniaturization of products allow 5F use •  Small radial arteries may not be suited for 6F guides •  Less spasm, less patient discomfort •  Lower incidence of radial vessel occlusion •  Less contrast/ injection = less nephrotoxicitySheba Medical CenterTel Hashomer The Leviev Heart Center
  31. 31. My Way… Works in >95% of cases •  Lidocaine 2% 0.5cc •  Dedicated radial sheath: Terumo, Cordis 6FR •  IA verapamil 2.5 mg •  IV heparin 3000-5000U •  Diagnostic catheters 5FR– JL3.5 + JR4 •  Guiding catheters 6FR – XB3.0 or JR4Sheba Medical CenterTel Hashomer The Leviev Heart Center
  32. 32. Conclusions •  Room setup is crucial •  Radial puncture – follow rules –  Use only dedicated radial kits •  NEVER push against even minor resistance •  Find the catheter that works best for you – Practice makes perfect •  Catheter engagement and support represent significant barriers to transradial procedural success –  Keep the guidewire in the catheter until you cannulate •  Knowledge of catheter selection and technique enable successful PCI •  Complex PCI is achievable with existing equipment –  CTO, bifurcations…. •  TR specific guiding catheters may offer advantagesSheba Medical CenterTel Hashomer The Leviev Heart Center

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