Hội Tim mạch học Việt Nam PCI support short

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<0.05
52.5
35.0
17.5

0
TRI

TFI

Judkins L can generate greater backup force in TFI than in TRI


Supports from guiding catheter
JL-4.0
JL-3.5
BL-3.0

JR-4.0 or 3.5

F1

Re

E0

F2

tio
n

Supporting
point

act

F1

ion

Active
point

Ac

F3

c
a
b
g
n t
o
r
r
t
o
S pp
su

p
u
k

F0

LCA

Supporting point

Active
point
E0

Action R
eaction

RCA

c
a
B

F0

p
u
k

p
u
s

rt
o

p

Trans-radial Superior high take off


Supports from guiding catheter
λ
Fmax = ――――
cosθ

Judkins Left JL 4 vs JL 3.5
45.0
resistance (gram force)

P<0.05

θ4

θ 3.5

33.8

22.5

11.3

0
JL 4

JL 3.5

Judkins L 3.5 can generate greater backup force in TRI than JL4.


Supports from guiding catheter
λ
Fmax = ――――
cosθ

Ikari vs Judkins Left
90.0
resistance (gram force)

P<0.001

θj

θi

67.5

45.0

22.5

0
JL 4

IL 4

Ikari L can generate greater backup force than Judkins L in TRI


Supports from guiding catheter
Considerations about the static friction

15mm

Static friction

35mm
λ
Fmax = ――――
cosθ

P<0.05

45mm

25mm
IL 3.5


Supports from guiding catheter
2

Co-axial position

θ
1

2

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 catheter
Engaging & power position
● Make the supporting point at lateral position of action & reaction
● Maintain the same direction with coronary artery ostium,
toward supporting point.

Active
point Ea

Active
point Eb

GCa

GCb

Fa

Power Position

Fb

Power Position


Supports from guiding catheter
λ
Fmax = ――――
cosθ

Judkins Left vs JL Deep engage
50.0
resistance (gram force)

P<0.05

θ4

θ4deep

37.5

25.0

12.5

0
JL 4

JL 4 Deep

Deep engagement increases backup force of Judkins Left.


Supports from guiding catheter
λ
Fmax = ――――
cosθ

Power position Of Ikari Left
90.0
resistance (gram force)

P<0.05

θi
θ4

θi power

67.5

45.0

22.5

0
IL 3.5

IL 3.5 Power Position

Power Position of Ikari L generates the greatest backup force


Pre-dilatation & pre-debulking

✓ Enough pre-dilatation
✓ Step by step dilatation
✓ Using higher pressure, larger, longer balloon
✓ Cutting balloon or balloon with buddy wire
✓ Rotablator (calcified lesion
✓ DCA


Pre-dilatation & pre-debulking
Acting mechanisms of Regular and Cutting balloons

✓Entire balloon surface contact the
vessel wall – arterial wall damage

✓Multiple rips and tears in media
✓Endothelium is completely
disrupted, large hematoma has
formed due to trauma

✓Injury localized to the scoring

sites - reduced trauma
✓Media with no visible disruption
✓Endothelial layer remains intact


Buddy wire or support wire




Deep engage - “amplatz” guiding


Deep engage - “amplatz” guiding