TECHNICAL & ENDOVASCULAR SESSION:
Engaging bypass grafts from the
radial approach
Sandeep Nathan,MD,MSc,FACC,FSCAI
Ass...
Cathetercourse:radialvs.femoral
Femoral
1 point of
resistance
Right Radial
2 points of
resistance
Left Radial
1 po...
Traversingthesubclavianartery
Distortionofaorticarchanatomywill
affectcathetercourseandtorqueability
Type II
Type III
RIGHTRADIAL
• Ergonomics(+)
...
DistortionofthebrachiocephalicͲ
aorticarchjunction
Patel’s Atlas of Transradial Intervention: The Basics.
Different loo...
““Bovine””aorticarchvariants
Common “bovine” arch
variants found in humans
Layton KF, et al. AJNR 2006 27: 1541-1542.
...
Difficultywithcatheterseating:
““Z””anglewith““bovine””archvariant
• Soft (0.035 in Versacore) wire and catheter support...
Arteria lusoria
CTA with 3-D surface rendering. Rotation from AP (1) to LAO (3) to PA (5)
1 2 3 4 5
• Retro-esophageal ...
Retro-esophageal insertion of an aberrant right subclavian artery
• Not a true ring , usually asymptomatic
• Sometimes d...
Multiple anatomic challenges from right radial:
Radial tortuosity, 2 consecutive radial loops + subclavian tortuosity
• ...
Multiple anatomic challenges from right radial:
Radial tortuosity, 2 consecutive radial loops + subclavian tortuosity
0....
Engaginggrafts:Universalvs.Judkins catheters?
Advantages
• Single pass through radial artery = potentially
less time an...
Engagingbypassgraftsfromthewrist
Othercathetersworthconsidering
JR4 MPA1 AL1 Cobra C1 Cobra C2 Non-torque right IMA RIM VB-1
Catheterselection:Keyconsiderations
• ProbablynoclearadvantageforLradialvs.RradialforSVGengagement
• TortuosityinRsubcla...
Accessingthenativecors,sequentialSVG
RIMAfromRradial
• 5 Fr IMA catheter used to engage SVG (Y-graft) to LAD and D, and ...
Accessingthenativecors,sequentialSVG
RIMAfromRradial
• 5 Fr IMA would not adequately engage RIMA due to subclavian angle...
Accessingthenativecors,sequentialSVG
RIMAfromRradial
• JL4 was too large and JL3.5 would not engage in a co-axial fashio...
Engagingthenativecors,LIMAand
SVGsfromtheRradial
• 5 Fr Cobra C1 introduced into transverse aortic arch and rotated
clo...
Engagingthenativecors,LIMAand
SVGsfromtheRradial
• 5 Fr Cobra C1 now advanced further and rotated clockwise with test
i...
Engagingthenativecors,LIMAand
SVGsfromtheRradial
• C1 catheter rotated counter-clockwise and withdrawn into arch and
th...
Accessing the LIMA from R radial
R radial access, Cobra C2 over 145
cm Wholey wire
R radial access, 0.014 in x 190
cm ...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Puttingitalltogether:
Nativecoronaries+grafts+PCIfromthewrist
69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVG...
Guideselection:GuidesforSVGPCI
Sizing suggestions:
Lateral takeoff/small root = MAC30
Superior takeoff/small root = MAC35/40
Superior takeoff/large ro...
GuidesforSVGPCI:
MultiͲAorticCurve(MAC)3.0/30
MAC 3.0/30
Angled Tip
ALR12
GuidesforSVGPCI:
ALR1Ͳ2
Comparable to:
Cordis: Castillo
GuidesforSVGPCI:
KR4H(horizontal)/S(superior)
GuidesforSVGPCI:
5FrIkari 1.0RforSVGtoOM
GuidesforSVGPCI:
6FrIkari 1.5RforSVGtoLAD
GuidesforSVGPCI:
6FrIkari 1.5RforSVGtoLAD
GuidesforSVGPCI:
6FrMBͲ1forSVGtoRCA
Summary
• Diagnostic catheterization PCI of SVGs (or through SVGs) is very
feasible fr TR approach
• Knowledge of the ...
TThhaannkk yyoouu!!
Nathan S - AIMRADIAL 2014 Technical - Post CABG
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Nathan S - AIMRADIAL 2014 Technical - Post CABG

Diagnostic and PCI for post CABG
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Nathan S - AIMRADIAL 2014 Technical - Post CABG

  • 1. TECHNICAL & ENDOVASCULAR SESSION: Engaging bypass grafts from the radial approach Sandeep Nathan,MD,MSc,FACC,FSCAI Associate Professor of Medicine Director, Interventional Cardiology Co-Director, Hans Hecht Cardiac Catheterization Laboratory University of Chicago Medical Center Chicago, IL
  • 2. Cathetercourse:radialvs.femoral Femoral 1 point of resistance Right Radial 2 points of resistance Left Radial 1 point of resistance
  • 3. Traversingthesubclavianartery
  • 4. Distortionofaorticarchanatomywill affectcathetercourseandtorqueability Type II Type III RIGHTRADIAL • Ergonomics(+) • Easeofentering descendingaorta • Longerdistanceto periphery • Tortuouscathetercourse inTypeIIͲIIIarches LEFTRADIAL • Shorterdistancetothe periphery • Greaterequipmentoptions • Ergonomics(Ͳ) Type I
  • 5. DistortionofthebrachiocephalicͲ aorticarchjunction Patel’s Atlas of Transradial Intervention: The Basics. Different loops which may be formed when the normal innominate-arch junction is distorted: 1. Normal anatomy 2. Z loop 3. Roller Coaster loop 4. Cobra loop 1 2 3 4
  • 6. ““Bovine””aorticarchvariants Common “bovine” arch variants found in humans Layton KF, et al. AJNR 2006 27: 1541-1542. True bovine arch found in cattle
  • 7. Difficultywithcatheterseating: ““Z””anglewith““bovine””archvariant • Soft (0.035 in Versacore) wire and catheter support utilized with hemostatic valve on back of catheter. • Judkins catheters may be easier to maneuver than universal curves in this situation
  • 8. Arteria lusoria CTA with 3-D surface rendering. Rotation from AP (1) to LAO (3) to PA (5) 1 2 3 4 5 • Retro-esophageal insertion of an aberrant right subclavian artery (arrow) • Usually associated with significant distortion of the junction between the subclavian artery and the aorta (at the level of the distal arch or proximal descending thoracic aorta)
  • 9. Retro-esophageal insertion of an aberrant right subclavian artery • Not a true ring , usually asymptomatic • Sometimes dysphagialusoria(lusoriadysphagiasyndrome) when dilated subclavian artery compresses esophagus posteriorly Arteria lusoria
  • 10. Multiple anatomic challenges from right radial: Radial tortuosity, 2 consecutive radial loops + subclavian tortuosity • Soft, angled Glidewireadvanced through a 4 Fr Glidecatheter • Untethered radial loops straightened out and catheter advanced
  • 11. Multiple anatomic challenges from right radial: Radial tortuosity, 2 consecutive radial loops + subclavian tortuosity 0.035 in x 175 cm Wholey wire advanced with 5 Fr JL 3.5 catheter into aortic root
  • 12. Engaginggrafts:Universalvs.Judkins catheters? Advantages • Single pass through radial artery = potentially less time and less spasm Disadvantages • Cost • Learning curve • Potentially more catheter manipulation Advantages • Cost • Familiarity / availability Disadvantages • More time • More passes through radial artery potentially = more spasm Tiger Jacky Ultimate JL4 JR4 pigtail
  • 13. Engagingbypassgraftsfromthewrist
  • 14. Othercathetersworthconsidering JR4 MPA1 AL1 Cobra C1 Cobra C2 Non-torque right IMA RIM VB-1
  • 15. Catheterselection:Keyconsiderations • ProbablynoclearadvantageforLradialvs.RradialforSVGengagement • TortuosityinRsubclavianmayimpactyourcases • Cathetermanipulation • Guidelengthrequiredtoengage(+lengthofgraftyouneedto traversewithinterventionalequipment) • IpsilateralIMAengagementisusuallyeasierthancontralateralIMA engagement • BilateralIMAs:Rradialwithcrossovertoleftisprobablyeasierthanthe opposite • SVGengagement:alwaysworthtryingwhatyoualreadyhaveinthe body(i.e.JR4,IMA,etc.)
  • 16. Accessingthenativecors,sequentialSVG RIMAfromRradial • 5 Fr IMA catheter used to engage SVG (Y-graft) to LAD and D, and then rotated to engage RCA
  • 17. Accessingthenativecors,sequentialSVG RIMAfromRradial • 5 Fr IMA would not adequately engage RIMA due to subclavian angle • 5 Fr VB1 catheter was used to engage the RIMA
  • 18. Accessingthenativecors,sequentialSVG RIMAfromRradial • JL4 was too large and JL3.5 would not engage in a co-axial fashion • The JL3.5 was deliberately folded in the noncoronary cusp, rotated, advanced into L cusp and then LMCA engaged from below as catheter tip straightened with wire
  • 19. Engagingthenativecors,LIMAand SVGsfromtheRradial • 5 Fr Cobra C1 introduced into transverse aortic arch and rotated clockwise (pointing posterior in aorta) and advanced to the L subclavian ostium
  • 20. Engagingthenativecors,LIMAand SVGsfromtheRradial • 5 Fr Cobra C1 now advanced further and rotated clockwise with test injections and pressure monitoring • LIMA intubated carefully and injections taken
  • 21. Engagingthenativecors,LIMAand SVGsfromtheRradial • C1 catheter rotated counter-clockwise and withdrawn into arch and then manipulated into aortic root • C1 used to engage RCA and LMCA • C1 rotated to identify stumps of 2 occluded grafts (SVG to RCA and FRA to OM)
  • 22. Accessing the LIMA from R radial R radial access, Cobra C2 over 145 cm Wholey wire R radial access, 0.014 in x 190 cm PT2-MS through Cobra C2 Cobra C2 advanced past IM os, withdrawn slightly, rotated counterclockwise
  • 23. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JL 3.5 diagnostic catheter
  • 24. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JL 3.5 diagnostic catheter 6 Fr JR4 diagnostic catheter
  • 25. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JR4 diagnostic catheter 6 Fr IMA diagnostic catheter
  • 26. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr NTR diagnostic catheter
  • 27. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 1.25mm followed by 1.5mm rotational atherectomy burr RCA after rotational atherectomy 6 Fr LARA guide catheter 6 Fr LARA guide, 0.014 x 300 cm Terumo RunThrough guidewire exchanged for a 300 cm RotaSupport wire, 1.25 mm then 1.5 mm burrs (total 4 runs / 20 passes)
  • 28. Puttingitalltogether: Nativecoronaries+grafts+PCIfromthewrist 69 y.o. man with a history of CABG (LIMAÆLAD, SVGÆRCA, SVGÆOM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 3.0 mm DES x 2, 20 ATM deployment, post-dilatation with NC balloon (24 ATM)
  • 29. Guideselection:GuidesforSVGPCI
  • 30. Sizing suggestions: Lateral takeoff/small root = MAC30 Superior takeoff/small root = MAC35/40 Superior takeoff/large root = MAC40 Lateral takeoff/large root = MAC45/40 Comparable to: Cordis: BRC (Block Technique) BSC: Radial Curve, Brachial Curve GuidesforSVGPCI: MultiͲAorticCurve(MAC)
  • 31. GuidesforSVGPCI: MultiͲAorticCurve(MAC)3.0/30 MAC 3.0/30 Angled Tip
  • 32. ALR12 GuidesforSVGPCI: ALR1Ͳ2 Comparable to: Cordis: Castillo
  • 33. GuidesforSVGPCI: KR4H(horizontal)/S(superior)
  • 34. GuidesforSVGPCI: 5FrIkari 1.0RforSVGtoOM
  • 35. GuidesforSVGPCI: 6FrIkari 1.5RforSVGtoLAD
  • 36. GuidesforSVGPCI: 6FrIkari 1.5RforSVGtoLAD
  • 37. GuidesforSVGPCI: 6FrMBͲ1forSVGtoRCA
  • 38. Summary • Diagnostic catheterization PCI of SVGs (or through SVGs) is very feasible fr TR approach • Knowledge of the graft anatomy formulation of a case “strategy” is critical • Key considerations relating to catheter manipulation / seating include: • Height type of aorta (I, II, III) • Subclavian tortuosity and loops • Number, type and location of grafts • Insure that you have a complement of common guide curves available (JR4, 3DRC, RCB, LCB, Ikari R, IMA, Amplatz)
  • 39. TThhaannkk yyoouu!!

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