Vorhofflimmern

CTO tool kit: Getting therevascular access, guiding catheters and other tools

Nicolaus Reifart, Bad Soden, D

Donor vessel guideTarget vessel guide

It all works more or less (as long as your guide is seated well) Vascular Access

Femoral vs Radial 2008-13 ERCTO

20% radial3

Or to ease the procedure:The parallel sheaths

7/8 F and 4/5/6/7 F

N. Reifart 2004

Optimal access to the coronary

Sheaths: have long Arrows available0.035 er wires (regular, lubricious, extra stiff)Guiding catheters: wide variety of 6/7/8 F

Standard sheaths dont work !!!!

Advantage of Arrow-Sheath(45-80 cm)

8The clue to this problem is a long kink-resistant sheath if the friction persists then select one F-size larger and you will be exites how the friction will decrease

8F Arrow 45 cm+ Amplatz extra stiffEven a 5F cannot be insertedWhat now ?

9

The parallel sheath-techniqueWith 2 Amplatz extra stiff wires

After2. Amplatz extra stiff wire

Procedure finished successfully in < 45 min

11

Eurointervention 2013Finecross + Monorail6F2 FinecrossValet+IVUSValet+Finecross

Eurointervention 2013Finecross + Monorail6F2 FinecrossValet+IVUSValet+FinecrossAllthough feasable in vitro, consider friction in the body!

7F

2 Corsair microcatheters 3 smaller devices such as two FineCross MC and a monorail anchoring balloon. Eurointervention 2013

8FStingray + 1.25 OTW2 Corsair + RX2 Corsair+IVUSVenture+Corsair+IVUSEurointervention 2013

6F7F + 50%8F + 40%

Catheter Cardiovasc Interv 2004 ???17

Tortuous heavily calcifyed RCAShort functional occlusion

1st attempt failed to cross a wire

7F AL 1

After Corsair + Pilot 50extrasupport wire+ balloon 2.5 mmStent cannot be placed

19

Guideliner

20

Stent placement wo problems

21

Femoral- left

My preference 7 F

EBU

JL

AL

Femoral- rightPreferably 7 FAllways sideholes!Cave Amplatz Left

AR

IMA/SC

JR

AL !

CTO RCA2nd attempt

AL 150897549/14

Corsair & floppy wire

Dissection due to subplaque injection

Change to JRBut still no access to true lumen.

Final result after subintimal progression

6 weeks later 7F JR1

final

7F10 cmWhat if your retrograde guide is too long ?

7 F6F

After enlarging the entries

7 F 90 cm

SummaryMany ways to Rome Find your preferable one that allows easy access, safe and firm support, perfect steerability, and that hosts all the devices you need without friction.Dont accept compromises to miniaturize your sheath-size !

Side Holes?Especially if a 7 Fr or 8 Fr catheter is selectedIn small coronariesIn very proximal and ostial lesionsTo avoid pressure dampingTo avoid vessel dissection if a strong dye injection is performedTo avoid catheter thrombus formation?

90cm Guides

For donor limbEspecially in epicardial crossing collateral

Shorten a 100 cm to 90 cm is feasable :

Medtronic Launcher in 90cm lengths:

6F + 7F Bypass Curve7F + 8F Amplatz Left7F + 8F EBU7F + 8F Right Standard7F + 8F Amplatz Right

6F7F8F2 MC+++Anchor B + MC+++1 MC + 1 Corsair++CrossBoss/StingrayExtension wire+++CrossBoss/StingrayBalloon trap+Reverse CART+++IVUS Guidance+++

Guide Size Compatibility

Ostial RCAAngina CCS 2Age of occlusion unknown

JR 46F

Hockey-stick

Insufficient BUAchoring impossible

AL1Very cautious injection

JR 4No chance to reenter

B: maneuverability without friction1. long Arrow sheath2. good guiding position (well aligned)3. OTW balloon or microcathterKink resistant microcatheter (Finecross)Super-kink-resistant MC : CorsairLubricious guidewires (Confianza 9, Pilot)

Rotation in both directions reduces the frictionand enhances advancement

CorsairFlexible, lubricious, does not kink

Tortuosity:Good passive guide +Corsair to straighten the curves and reduce friction

C: getting balloon/stent to lesionBackup: Anchor-wire or balloonGuidelinerBypass excentric plaque/calcium: Corsair/TornusParallel wiresRotablator

According to my experience7F 100%Parallel sheaths 100% of CL (75% of CTO)Long Arrow sheath 30%Corsair: 90 %Balloon-anchor 5%Guideliner: 5 %Confianca 9: 70% (sensitive handling)

Example of the Sensitive-Corsair-Confianza Strategy

CTO CX13 months old18 mm longNoncalcifyedVery tortuous access (2x 90 degrees)2nd attempt

JCTO: 1(+)18 mm5088194

After crossing 2 bends with floppy wireCorsair to straighten and ease manipulation with Confianza 9

Sensitive C9 handling

FinalProc. Time: 40 minFluoro: 7.2 minDye: 110 ml0.25 Gy

Results of this simple strategyCases 2010-2014:Success:Sucess 2nd attempt: Procedural time:Fluoro-time:Retrograde: Success: Radiation (mGy):

Anchor-Balloon

59

Guiding Catheters

I Strongly recommend 7F90% EBU for Left70% Amplatz right 2 for RCA, allways with SH + CAVE Amplatz left