Lựa chọn ống thông can thiệp mẹo để hỗ trợ can thiệp và giảm biến chứng

• Chọn lựa ống thông can thiệp là chìa khóa giúp mở cánh cửa thành công trong can thiệp mạch vành... • Conduit for transporting guide wire & devices • Mode for injecting contrast • Pla

Lựa chọn ống thông can thiệp:

Mẹo để hỗ trợ can thiệp

và giảm biến chứng

PGS TS Hồ Thượng Dũng, FSCAI

BV Thống Nhất, TP HCM

• Chọn lựa ống thông can thiệp là chìa khóa giúp mở cánh cửa thành công trong can thiệp mạch vành

Chức năng và đặc điểm của

Ống thông can thiỆp

• Conduit for transporting guide

wire & devices

• Mode for injecting contrast

• Platform for back up support

during intervention

• Mechanism for measuring aortic

& arterial pressures

Chức năng của ống thống can thiệp

.070”

Polymer Blend

Back up support Curve retention Shaft stiffness

Wire Braid

Kink resistance Torque response Shaft radiopacity

Inner Liner

Device Passage

Ống thông can thiệp so với

Ống thông chẩn đoán

• Stiffer shaft

• Larger internal diameter (ID)

• Shorter & more angulated tip

• Re-enforced construction

• (3 vs 2 layers)

• Tip Non Tapered

• Tip May be Soft or Radiopaque

Các đặc tính quan trọng cần thiết của

Ống thông can thiệp

Many Principles similar but some variations in size

and catheter types to accommodate various devices

Cấu tạo và cấu trúc của

Ống thông can thiỆp

Cấu tạo- cấu trúc của ống thông can thiệp

Overall stiffness

Torque Generation

Smooth passage delivery of devices

Lòng ống thông can thiệp lớn hơn

Curve/Tip Length

3.0 4.0

Tip Length = P to S distance (cm)

Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization,

Đặc điểm và cơ chế hoạt động

MỘT SỐ Ống thông can thiỆp

Chọn lựa ống thông can thiệp

•Designed for LCA interventions

•Simple straightforward PCI

•Easy to engage LCA

•As the primary curve is fixed, the GC may not be co-axial with the index artery

•Sometimes may be difficult to pass balloon/ stent

•As the primary curve is fixed, LCX PCI may

be difficult to pass balloon/ stent

•If the LCA have high take off, increase risk

of prolapsed and dislodgement

•Weak back up support

Judkins Left

Left Guide Catheters Curves

Left Judkins Manipulation

Dehmer & Popma: Cathsap III

Left Judkins Manipulation

Tip Orientation Lateral Wall Support

Curve/Tip Length

Normal Narrow Dilated

Normal root size usually

requires a primary curve of 3.5

Aortic Root Size

How to select the size of the catheter

Co-axial Alignment

Amplatz Left

•Particulary useful for posterior and anterior Take-off

•Niche use for LCA interventions

•Rest on the aortic root, providing for addition back up support

•Prone to dissect the ostium

Left Guide Catheters Curves

Amplatz Manipulation

Dehmer & Popma: Cathsap III

Amplatz Removal

Chú ý dễ bị bóc tách

Advance catheter Rotate tip away from ostium

Right Judkins Manipulation

Dehmer & Popma: Cathsap III

Right Judkins Manipulation

Chọn lựa sử dụng

Ống thông can thiỆp

trong một số tình huống

Tại sao có quá nhiều loại ống thông hình dạng và kích thước khác nhau?

• Left or right coronary system

• No two anatomies are the same

• Large or small patients

• Small or enlarged aortas

• Different vessel take off

• Lesion morphology & location

• Device strategy

Choice of Guiding Cath for LCA

Left Coronary Artery Catheter Selection

• AL1, AL2, AL3

• Multi Purpose (MPA)

Right Coronary Artery Catheter Selection

Xoay JL để hướng vào LAD/LCx

Counter-clockwise LCX Clockwise LAD

■ For the superiorly oriented ”shepherd’s crook” take-off

− In the past many would chosen AL 1 or 2

− The Tiger catheter is a modern day alternative

− Present day practice also allows the use of a guideliner to provide support and minimize dissection risk

■ For the inferiorly oriented RCA take-off: many would choose a

multipurpose guider but caution must be used to avoid overly deep seating with dissection possibility

Vessel Take-off Variations- RCA

Shepherd’s Crook- superior Transverse Inferior

6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 31

Anomalies of origination and course

High take-off above the Sinotubular Junction

Chest 1986;89:668–672

Sang et al, Asean Heart J 2011

Anomalous RCA- ACAOS

Suggested guiders for PCI on

Internal Mammary

Artery Grafts

Saphenous Vein Grafts

Graft Cannulation

Internal Mammary Artery (IMA) Grafts

• IMA

• Judkins Right (JR)

Graft Cannulation

• most commonly use

•Not suitable for abnormal take off Judkin Right

Graft Cannulation

Multi Purpose A1

•Useful for SVG to RCA

•Straight down inferior take off

GC selection for SVG

Các biến chứng khi sử dụng

Ống thông can thiỆp

& CÁCH PHÒNG NGỪA

Cath induced LMS dissection

Class 1 Dissection Into the Right Coronary Cusp Successfully

Treated with Stent Implantation

Class 2 Dissection Just Above RCA Ostium

Những điều cần chú ý để giảm

biến chứng của ống thông can thiệp

GUIDE CATH CARE

• Aspirate vigorously

- thrombus

• Insist on ‘bleed back’

- Prevent air embolism

• Avoid blood standing in GC

- Flush frequently

• Proximal ostial disease

- Avoid amplatz

Một số mẹo mực trong sử dụng

Ống thông can thiỆp

Để giảm biến chứng và tăng cường hỗ trợ can thiệp

Các biện pháp tăng khả năng chống đỡ

(Support, Back-up) của ống thông

• Passive Guide Support:

• Increasing support with big stiff guides

• Active Guide Support

• Intubating arteries with small flexible guides

• Enhancing Guide Support with extenders:

• Guideliners, Mother/Child techniques, etc…

• Various others:

• Buddy wires, anchors balloons, etc…

Large long Sheath:

Planning for Optimal Guide Support

• Access Stabilization

# 8 Fr Long (45 cm) femoral sheaths

Sidehole (SH) at Guide Cath

Advantages

• Prevent cath damping

• Allow additional blood flow to

perfuse the artery

• PCI in Small vessel intervention

• PCI in CTO lesion

• Sideholes recommended for RCA

Passive guide support:

Sheath-less 7 fr system: 1.5/1.75 rotational atherectomy followed by DES

Active Guide Support Active Guide Support:

Guide Stabilization and Deep Seating

Guide Stabilization and Deep Seating

GuideLiner creates coaxial alignment in any position, provides deep guide engagement and greater support (guide in guide),

GUIDE EXTENSION

Guide Extension Clinical Uses

• Deep seating for added back-up support

• Coaxial guide alignment

• Selective distal contrast delivery

• Protected distal stent delivery

Mother Child Support with Guideliner

Guide catheter

distal tip

GuideLiner

distal tip

Distal Stent Delivery

Guide Catheter tip

GuideLiner

Stent

Anchoring techniques:

1 2nd wire

(Ironman) in branch proximal

to CTO

2 3rd wire

(Ironman) in branch

3 2.0 Balloon

inflated in branch (coating wiped off)

Antegrade Anchoring

1.5 balloon

1.5 balloon

CTO of RCA

Antegrade Anchoring

What to Watch Out for

• Dissection from tip entry

• Hydraulic dissection

• Wire behind Liner

• Wire wrap on hypotube

• Kinking of catheter when “overextended”

• Shearing wire on collar

When All else fails

Do You have Everything?

• You can't always get what you want

• But if you try sometimes well you just might find

• You get what you need

RICHARDS, KEITH / JAGGER, MICK

You can’t have everything

Summary & Conclusions

success

important benefits

• Guide catheter selection depends on access

approach, anatomy, lesion location and

morphology

■ Honing/Practising of catheter skills is crucial

to coping with challenging anatomy

■ We need to select our own catheter series

and perfect our manipulative skills

( practice makes perfect )

Principle

• Varying guide sizes can offer increased

active or passive support

particularly when deap seated

make substantial impacts

Principle