PCI for calcified and tortuous vessels Nguyen Ngoc Quang, MD, FASCC Dept of Cardiology, Hanoi Medical University Vietnam National Heart Institute Key Points in DES era ✓ The simpler procedure the better outcome ✓ Debulking device plays a small role except calcified or some special kinds of lesion (bifurcation, ostial, ISR…) ✓ Longer DES is frequently used (33, 38 mm…) - “from shoulder to shoulder” principle ✓ Safe DES implantation is important for long term outcome ➠The deliverability of long stent is not good especially in the calcified or tortuous lesion Strong guiding catheter with supportive wire Enough pre-dilatation or debulking Buddy wire or support wire Deeply engage or “amplatz” guiding Mother-child (5F) catheter technique Anchor technique Supports from guiding catheter In complicated lesion we should initially use support catheter instead of Judkins catheter For RCA: AR, AL, Hockey, Champ, RCB Supports from guiding catheter In complicated lesion we should initially use support catheter instead of Judkins catheter For LCA: XB, EBU Supports from guiding catheter Influencing factor of Back up support Friction & slipping Shape of catheter Stiffness Pushing & pulling of shaft, Torque control Supports from guiding catheter ØThus, Maximun backup force (Fmax) is: Ø If Fcosθ ≤ λ (static friction), the guiding catheter works Ø If Fcosθ > λ, system collapses λ Fmax = ―――― cosθ λ = static friction within the aorta wall F = back-up force Supports from guiding catheter JL-4.0 Trans-femoral JL-3.5 Voda-3.0 Active point F1 Supporting point F2 E0 F3 F0 ac b g n o rt r t S po sup p u k A n o i t c e r & n o i t ac Supports from guiding catheter JL-4.0 Trans-radial JL-3.5 BL-3.0 F1 Supporting point Active point F2 E0 F3 F0 c a b g n t o r St por p u s p u k A n o i ct Re n o i t ac Supports from guiding catheter λ Fmax = ―――― cosθ Judkins Left TRI vs TFI resistance (gram force) 70.0 θr θf P 0.070 in (without self-created side holes) 5F child catheter (20cm longer than mother catheter) (5F ST GC - Terumo Co.) Child catheter can advance further to across the stenotic or tortous lesion → No risk of stent dislocation, stent deformity or DES polymer peeling off, especially long stents Using 5F straight guiding catheter Potential complications Vessel injury • Gently advancement of child catheter into the coronary artery Intra-coronary or intra-guiding catheter thrombus • Careful monitoring distal coronary pressure Air embolism • Occur when child catheter is wedged, suck back too strong or angiography after stent deployment • Check the blood back flow from Y-connector just after stent deployment (Air embolism will Using 5F straight guiding catheter Using 5F straight guiding catheter Using 5F straight guiding catheter Using 5F straight guiding catheter Anchor technique Side branch anchor Peripheral anchor Anchor technique Anchor technique Anchor technique Anchor technique Anchor technique Strong guiding catheter with supportive wire Enough pre-dilatation or debulking Buddy wire or support wire Deeply engage or “amplatz” guiding Mother-child (5F) catheter technique Anchor technique Conclusions ✓ Appropriate choosing & manipulating GC is crucial for long, calcified and tortuous coronary lesions ✓ 5F guiding catheter or 5in6 GC system are alternative approaches for tortuous coronary lesions with long stents ✓ Combined approach (buddy wire, anchor technique, 5in6 GC system) is necessary for special case Thank you very much for your attention ... catheter Co-axial position θ Supporting point F2 E sinθ F1 Supporting point E θ Action Reaction F2 Poor back up support when GC engages eccentrically to coronary artery ostium Supports from guiding... should initially use support catheter instead of Judkins catheter For RCA: AR, AL, Hockey, Champ, RCB Supports from guiding catheter In complicated lesion we should initially use support catheter... For LCA: XB, EBU Supports from guiding catheter Influencing factor of Back up support Friction & slipping Shape of catheter Stiffness Pushing & pulling of shaft, Torque control Supports from guiding