Tricks of handling difficult cannulations (GB Pant Hospital)

1. Tricks of handling difficult cannulations
Vipul Gupta
Neurointerventional Surgery
Artemis Agrim Institute of Neurosciences

2. Cannulations/Access
Aortic arch
ICA
Distal to aneurysm
Case studies ….

3. Arch Access

4. sheath

6. A
B C
Fig. 1 – DSA was done along with 3D angiogram. A broad neck lobulated
ICA aneurysm was seen (A). Marked tortuosity of aort and arch vessels
was noticed. Arrows in Fig. C outline the course of diagnostic catheter.

7. sheath

11. SIM in very tortuous

14. A B C
D E GF

15. Arch cannulation
What do I use?
Picard (Cook) for most – long sheath
Long sheath – Cook, Arrow, Penumbra – be
mindful of length
Wire in the ECA, if need be an excahange
SIM 2/3 for very tortuous – Amplatz for
exchange

16. Difficult ICA …

17. Guiding catheter in ICA
More important than usually realized
Envoy 6F – can take double systems
As high as possible, commonly in petrous ICA
Terumo 038
Prime with NTG, nimodipine

18. guiding
 Guiding in petrous using a
4/5 diagnostic catheter

19. Distal access catheters …..

20. Taking Neuron over wire …
Always need a long sheath

21. Co-axially over lower profile DAC
Long sheath
Guiding catheter – 6 F co-axial over longer 44
DAC
We could go through loops ….

24. G H
Long sheath Cook Raphe 70 cm
DAC - 6 F , 105 cm
DAC – 44 , 115 cm
Terumo – 35/38

25. A
B C D

26. A B
C D
E

27. Long sheath Cook Raphe 70 cm
DAC - 6 F , 105 cm
DAC – 44 , 115 cm
Terumo – 35/38
Prowler 21 ; Traxcess or other MC

28. If nothing works …
Old and best

32. Different cannulations
Distal to aneurysm …
• For balloon .
• For stent/FD

35. Buddy wire ….

45. Aneurysm cannulations

47. REVERSE CURVE

48. Cannulations …
Critical for success ….
Different strategies for arch, ICA,
intracranial access
Awareness of options and availability
of hardware
Long sheaths, distal access catheters
and co-axial options have changed
the game ….

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Dr Vipul Gupta