Lựa chọn ống thông can thiệp: Mẹo để hỗ trợ can thiệp và giảm biến chứng - Hồ Thượng Dũng

a: Cathsap III 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 21 
Amplatz Removal 
Chú ý dễ bị bóc tách 
Advance catheter Rotate tip away from ostium 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 22 
Right Judkins Manipulation 
Dehmer & Popma: Cathsap III 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 23 
Dehmer & Popma: Cathsap III 
Right Judkins Manipulation 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 24 
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 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
26 
Choice of Guiding Cath for LCA 
• Normal Aorta 
• JL4, XB 3-3.5, AL2 
• Dilated Aorta 
• JL5, XB4, AL3 
• More back-up 
• XB-LAD, EBU, XB 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
27 
Left Coronary Artery Catheter Selection 
• Judkins Left 
• JL3 
• JL3.5 
• JL4, JL4ST (Short Tip) 
• JL5 
• JL6 
• Amplatz 
• AL1, AL2, AL3 
• Multi Purpose (MPA) 
Source: The Manual of Interventional Cardiology 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 28 
Right Coronary Artery Catheter Selection 
• Judkins Right 
• JR3 
• JR3.5 
• JR4, JR4ST (Short Tip) 
• JR5 
• JR6 
• Amplatz 
• AR1, AR2 
• Hockey Stick 
• Multi Purpose (MPA) 
Source: The Manual of Interventional Cardiology 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 29 
Xoay JL để hướng vào LAD/LCx 
Counter-clockwise LCX Clockwise LAD 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
30 
 ■ 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 Inferior Transverse 
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 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 32 
Chest 1986;89:668–672 
Sang et al, Asean Heart J 2011 
Anomalous RCA- ACAOS 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
33 
Suggested guiders for PCI on 
Anomalies of RCA 
• JL 
• XB 4.0 
• AL 1.0, 2.0 
• Heartrail Ikari right 1.5 
• EBU 3.0 
• Leya catheter 
 . 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 34 
Internal Mammary 
Artery Grafts 
Saphenous Vein Grafts 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
35 
Graft Cannulation 
Internal Mammary Artery (IMA) Grafts 
• IMA 
• Judkins Right (JR) 
Source: The Manual of Interventional Cardiology 
Graft Cannulation 
• most commonly use 
•Not suitable for 
abnormal take off 
Judkin Right 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 37 
Graft Cannulation 
Multi Purpose A1 
•Useful for SVG to RCA 
•Straight down inferior take off 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
38 
GC selection for SVG 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 39 
Các biến chứng khi sử dụng 
Ống thông can thiỆp 
& CÁCH PHÒNG NGỪA 
Embolization 
• Air 
• Atheroma 
• Thrombus 
Dissection 
• Coronary artery 
• Subclavian or IMA 
• Aortic root 
• Abdominal aorta 
• Iliac artery 
Guiding cath Complications 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
41 
Cath induced LMS dissection 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
42 
Class 1 Dissection Into the Right 
Coronary Cusp Successfully 
Treated with Stent Implantation 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
43 
Class 2 Dissection 
Just Above RCA Ostium 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
44 
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 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 45 
Một số mẹo mực trong sử dụng 
Ống thông can thiỆp 
Để giảm biến chứng và 
tăng cường hỗ trợ can thiệp 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 47 
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 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
48 
Large long Sheath: 
Planning for Optimal Guide Support 
• Access Stabilization 
# 8 Fr Long (45 cm) femoral sheaths 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
49 
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 
– rarely necessary (RR-
measurement) 
Disadvantages 
•Sub-optimal opacification with 
contrast escape 
•Increase contrast 
•Weaken the cath shaft 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
50 
Passive guide support: 
Sheath-less 7 fr system: 1.5/1.75 rotational atherectomy followed by DES 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
51 
Active Guide Support 
5 french JR4 with balloon pre-dilatation and DES implantation 
Active Guide Support: 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
52 
Guide Stabilization and Deep Seating 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
53 
Guide Stabilization and Deep Seating 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
54 
GuideLiner creates coaxial alignment in any position, provides 
deep guide engagement and greater support (guide in guide), 
allows distal contrast injections and protected stent delivery 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
55 
GUIDE EXTENSION 
Guide Extension Clinical Uses 
• Deep seating for added back-up support 
• Coaxial guide alignment 
• Selective distal contrast delivery 
• Protected distal stent delivery 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
56 
Mother Child Support with Guideliner 
Guide catheter 
distal tip 
GuideLiner 
distal tip 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
57 
Distal Stent Delivery 
Guide Catheter tip 
GuideLiner 
Stent 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
58 
Anchoring 
techniques: 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
59 
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 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
60 
CTO of RCA 
Antegrade Anchoring 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
61 
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 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
62 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 63 
When All else fails 
• Start over 
• Trust you wire skills 
• Be persistent 
• Get help. 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, 
Hochiminh city, VN 
64 
When all else fails 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
65 
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 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 
66 
You can’t have everything 
Summary & Conclusions 
• Guide catheter selection is a key to procedure 
success 
• Catheter construction and design offer 
important benefits 
• Guide catheter selection depends on access 
approach, anatomy, lesion location and 
morphology 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 67 
 ■ Honing/Practising of catheter skills is crucial 
to coping with challenging anatomy 
■ We need to select our own catheter series 
(our familiar catheter series) that works for us 
and perfect our manipulative skills 
 (practice makes perfect) 
■ One size does not fit all 
Principle 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 68 
• Varying guide sizes can offer increased 
active or passive support 
• Guide extenders increase support – 
particularly when deap seated 
• Buddy wire and anchor techniques can 
make substantial impacts 
6/20/2016 
Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 69 
Principle 
6/20/2016 Ho Thuong Dung, Thong Nhat hospital, Hochiminh city, VN 70