li yue, m.d. the first affiliated hospital of harbin medical university stent or balloon delivery...

Li Yue, M.D.Li Yue, M.D.

The First Affiliated Hospital of

Harbin Medical University

stent or balloon Delivery

TRI: How to treat difficult

??

Guiding catheter Extra-support shape/ Increase size Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS)

Tips and tricks for stent delivery

导引导管支撑力 被动支撑

（取决于直径、结构、导管与主动脉壁接触面积和夹

角）

主动支撑（术者操作获得）

Deep seating

JL4.0

被动支撑力直径越大、支持力越强。

Radial artery diameter

The frequency of this ratio (≥ 1.0) for 7 and 8 Fr sheaths was 71.5% and 44.9% in male patients and 40.3% and 24.0% in female patients.

Male （ mm ） Female （ mm ）国外 3.1±0.6 2.8±0.6 魏盟 2.7±0.4 2.3±0.4

贾三庆 2.65±0.60 2.20±0.49

radial artery internal diameter / sheath external diameter

4% in patients with ratio >1 13% in patients with ratio <1

7F sheath external diameter = 3.0mm

The dosage of heparin, the diameter of radial artery

and the post-procedure compression pressure and

time were independent risk factors for RAO

Cathet Cardiovasc Diagn 1997;40:156–158

Sheathless GC system (Asahi Intecc, Japan)

hydrophilic GC + central dilator

桡动脉细又需强支撑、大内径导引导管怎么办 ？

The outer diameter of the 6.5 F sheathless GC (2.16 mm)

is smaller than a 5 F sheath (2.29 mm).

The outer diameter of the 7.5 F sheathless GC (2.49 mm)

is less than that of a 6 F sheath (2.62 mm).

Thicker than conventional guide catheters due to an addition layer of steel braiding and the hydrophilic coating, aids backup support.

After the diagnostic angiography, the sheath was exchanged f

or the sheathless catheter over a standard 150 cm J-tipped 0.

035-inch (Terumo®, Japan) wire.

Comparing the backup force between TFI and TRI

J Invasive Cardiol. 2005 Dec;17(12):636-41

It was found to be 60% greater

in TFI with a JL catheter, and

8% greater in TFI with a backup

(BL/EBU/XB) type catheter.

JL4.0

短头 Amplatz 导管

标准 短头

刮伤主动脉窦情况 大大降低，造成靶血 管撕裂、 夹层可能 降到最低

入冠不深，几乎没有 嵌顿现象

Heartrail II (Terumo, Japan)

long (120 cm) 5 Fr catheter (13 cm very soft end portion)

Absence of curve and the flexibility of its tip permit the

“child” catheter coaxial with the target vessel.

5 in 6 guiding catheter technique

Inner catheter

Filled with water that was kept at 37°C

5 mm/s

Switching to 5-in-6 system

7F AL-1; 3.5mm balloon

(Goodman, Japan)

The lumen size of the aspiration catheter as the size of SES is limited to 3.0 mm.

GuideLiner cath

Rapid exchange Flexible yellow 20 cm straight extension connected to

a stainless-steel push tube Results in an I.D. approximately 1F size smaller available in three sizes: 6F, 7F and 8F

Not recommend its use in target vessels of < 2.5 mm diameter

Softer tip and hydrophilic coating on inside and outside.

5-Fr ST01 has the coating only on the inside.

Catheterization and Cardiovascular Interventions 76:919–923 (2010)

(Terumo, Japan)

KIWAMI ST01

Backup support of GC

Circ Cardiovasc Interv. 2011 Apr 1;4(2):155-61

Trackability of GC

Using balloon-anchoring technique 5F child catheter could be advanced to 13.0 cm, w

hereas the 4F child catheter could be advanced to 15.

0 cm (P<0.005).

Provided >90% success rate for 51 lesions in which conventional techniques had failed.

Success may be contributed, in most part, by the

trackability of the 4F child catheter.

Does not usually compromise the coronary flow.

Cypher (3.0 × 18 mm)

Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS)

Tips and tricks for stent delivery

Anchor wire

Buddy Wire & Buddy Balloon

Provide the guiding catheter stability

Straighten the tortuous segment of the artery

Deflect the stent delivery system away from

the calcified area

Buddy Balloon

Inflated Buddy Balloon

LMS / ostial LCX

Predilated

2.5 X 15 mm balloon

3.5 X 10 mm cutting balloon

LAD

1.25, 1.5 bur

4.5 X 32 mm Liberty could cross

3.5 X 20 mm balloon

Buddy wire

Buddy balloon (3.5 X 20 mm)

Inflation of the buddy balloon to 2 atm, the distal stent edge was deflected enough from the plaque to allow its passage

3.0/14-mm balloon was placed at the lesion, SES was

placed at the proximal lesion.

Just after balloon deflation, SES was delivered to the

lesion easily.

Anchor balloon

Anchor in side branch Anchor in same artery

Super anchor balloon

Buddy - in – jail (Distal)

Buddy - in – jail (Proximal)

Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS)

Tips and tricks for stent delivery

旋磨头不能够通过怎么办 ？

Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS)

Tips and tricks for stent delivery

Antegrade PCI used a Fielder and Miracle 3 wire unsucc

essful. A large dissection in the RV branch.

A Fielder wire was advan

ced into the aorta retrograd

ely.

The retrograde balloon (V

oyager 2.0 -20 mm) inflated in

RCA.

Multiple attempts to pass

a guidewire antegradely w

ere unsuccessful.

Retrogradely passed a

2.5- 8 mm Mini-Vision ste

nt to the RCA ostium.

Subsequently, 5 more

Vision stents (2.5-12, 2.5-1

5, 2.25-12, 2.25-15 and 2.25-2

3).

Because the patient had previously undergone CABG with the risk of perforation from epicardial collateral passage consequently decreased.

Seesaw balloon-Wire cutting 技术

Seesaw balloon-Wire cutting 技术

球囊“挤撬”反复冲击、扩张

1.25×10m

m

纤维帽

多导丝挤压

Pilot 50

Pilot 150

Pilot 150

Mini TREK

1.2×6 mm

Sprinter

1.5×6 mm

×

×

How to do next ?

Pilot 150

Pilot 50Tazuna

1.25×10 mm

Tazuna

1.25×10 mm

Seesaw balloon-Wire cutting

反复“交替”

Technique Features and PCI ResultsResults (n = 21)

Procedure success related to Seesaw balloon-wire cutting technique, n (%) 16 (76.2%)

Technical failure, n (%) 5 (23.8%)

Due to inability to place a second guidewire 1 (4.8%)

Due to balloon unable passing 4 (19.0%)

Category of the second guidewire, n (%)

Pilot 150 9 (42.8%)

Pilot 200 8 (38.2%)

Progress 200T 4 (19.0%)

Mean time of successful Seesaw balloon-wire cutting procedure (mean ± SD, min) 26.4 ±7.7

Application of additional technique, n (%)

Rotational atherectomy with Rotablator, n (%) 3 (14.3%)

Overall procedure success, n (%) 19(90.5%)

Seesaw balloon-wire cutting technique related serious complication, n(%) 0

Tips and tricks

Polymer-coated and more stiff guidewire (pilot 150

or 200 ， Progress 200T ） as the second guidew

ire.

Short and low profile balloons (1.25×10mm tazun

a) are recommend .

More suitable for TRI or GC without

enough back-up support

JR4 JL3.5 AL1 AL2 BL3.0

Tazuna

1.25×10 mm

1.25×10 mm

Buddy-in-Jail

Tornus

One month later

Seesaw balloon-Wire cutting 技术

Journal of Invasive Cardiology Journal of Invasive Cardiology