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
ØThus,
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