`
`Director of Experimental Cardiology
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`David Meerkin
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`Shaare Zedek Medical Center
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`Jerusalem
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`of procedural failure
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`Factors
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`Poor back up i force before guide
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`displacement
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`Failure to deliver a stent is a frequent cause
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`
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`Tortuousity J, distal transmission of force
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`Friction between rigid stent and vessel wall
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`SVG PCI accounts for between 540% of PCI
`
`procedures
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`technically more
`procedures
`PCI
`SVG
`challenging than native coronary arteries
`
`
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`Previous CABG shown to increase failure rate of
`
`trans radial PCI procedures 7-fold.
`2(11):1057-1UB4.
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`JACC |ntv,2ii{19;
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`SVG—PCI include:
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`' Inadequate Guide Catheter Support
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`- Inability to reach ostium and cannulate SVG
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`- Difficulties encountered during
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`
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`- Competitive Flow
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`- Achieving deep seating of guide catheter in
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`SVG
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`- Extreme Tcrtucsity
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`Support guide - T force before
`
`displacement
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`Support I buddy wire
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`- reduce
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`tortuousity
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`
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`Lesion preparation I lower profile stent
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`- i friction
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`Distal anchor balloon
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`T backup support by locking guide
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`
`
`may increase friction (2 catheters in
`lesion)
`
`requires 2 7F to accommodate inflated
`
`balloon + stent
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`\ Guide looked in
`position allowing
`
`Stentoatheter
`advanced through
`
`proximal obstruotion
`
`1-—_
`
`Balloon inflated in distal
`
`vessel
`
`Distal anchor
`
`balloon — JR4
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`9 U ide
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`increased foroe on
`
`stent before
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`displacement
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`Need :2 ?F
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`Guide catheter extension
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`Greatly increases back-up support
`
`. Shape modification ‘Amplatzing' T contact in aorta
`
`- Deep intubation increases contact within the coronary
`artery
`
`
`
`Can be advanced through proximally deployed
`stents
`
`May traverse proximal obstruction
`
`- more flexible than a stent
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`Can be advanced using distal anchor balloon
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`- Requires only 6F without need for 2 catheters in lesion
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`- Permits proximal to distal stenting
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`JR4 guide
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`limited support
`
`from contact with
`
`Support from conventional JR4 guide
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`
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`H
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`opposite aortic
`wall
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`resistance to stent passage
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`causes guide to back out —
`
`backup is lest as guide
`comes away from coronary
`
`Guide catheter backing out
`
`
`
`esteum & aortic wall
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`“Mother and Child”
`
`5F through standard 6F
`(CordislMedtroniclBoston etc) guide
`
`
`
`Classically used
`
`Terumo Heartrail 125cm guide
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`Mechanisms of increasing backup with guide
`catheter extension
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`Shape change of guide
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`Deep intubation of coronary
`
`
`
`Deep intubation
`
`adds greatly
`
`increases contact
`
`within coronary
`
`artery greatly
`
`increasing support
`
`\
`
`'1
`
`If
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`Shape change of JR4 into
`
`‘Arnplatz Left' shape increases
`
`contact aorta increasing support
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`Coaxial
`
`“mother and child”
`
`
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`guide extension
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`with
`
`rapid exchange
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`convenience
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`3' 20cm guide extension connected to
`
`
`
`-" Guidewires, balloons and stents
`
`enter the GuideLiner’s collar within
`
`the guide catheter
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`a push-rod with a “collar”
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`= Flexible GuideLiner extension can
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`be deep seated for mother-and-child
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`back-up support
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`3 3 3
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`
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`Guide catheter
`
`Tip of GaideLiaer
`
`GaideLiaer
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`positioned at ostiam
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`deployed into
`
`advanced diataiiy up
`
`off? CA
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`RCA
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`to I Oem into vessel
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`Distal anchor to insert Guideliner,
`staged stent insertion
`
`Guidelineradvanced1;' t
`through proximal
`_
`2
`'
`[H
`obstructionrn
`\
`Anchor balloon
`
`I
`
`i.
`'\
`
`Guide locked in position allowing
`
`increased force on Guideliner
`
`before displacement 6F
`
`removed after
`
`Guideliner crossing
`
`
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`Balloon inflated in distal
`
`vessel
`
`Stent advanced without
`
`resistance within Guideliner
`
`catheter
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`Severe proximal
`
`disease causes
`
`pressure damping E‘s!-
`
`prevents serenary
`
`intubatien
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`Severe proximal and distal disease
`
`
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`Distal disease eann
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`be reached
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`Guideliner assisted proximal then
`distal stenting
`
`stent undeployed
`
`stent expanded opens
`.
`proXImal vessel
`
`Guideliner advanced
`
`through deployed stent
`allowing access to distal
`h
`iKt: vessel
`
`“a.
`
`'5.
`~. K:—
`Halon—r"
`
`
`
`Guideliner increases
`
`support to allow stent
`
`advancement into
`
`proximal lesion
`
`I
`
`.
`
`J
`
`‘1 all.
`
`I.
`I“.
`"my
`$3173.;—
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`r"
`
`*5
`_.?-:
`
`.I--' 'L .
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`WHQIEIfimuPCIENEW] — unramed
`
`
`
`Irrage S'ze: 5|? :x'SIE
`View SiZE‘Z 506 :x: EIUE-
`
`W; 102 W'III’: 202
`
`13—15% fing'e- F]
`Fmr‘r'
`Irr: 1336
`
`Uncompfiessed
`
`EEQUIUQ
`14
`
`ESHUEII’EUUQ 39:54:25
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`Made In DSifiH
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`INEQESZEZS123512
`View SiZE‘Z 506 :x: «EOE
`
`W; 91 WW: 13:1
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`,
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`..
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`ME T9233! "My?
`Angiografl-PCIIINENZI — mrarred
`
`EEQUIUQ
`15
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`Fmrr: Fifi fing'e: [‘1
`Irr: 1342
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`
`ESIUEIEUDQ 10:10:47“
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`Made In DSPiH
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`Irrageaize:512 36.512
`View Size: EOE: 3: E06
`W; 92 WW 15:3
`
`|"1| 723“ My]
`Angiogram-PCIHEW] — unnarred
`EEHUNJH
`
`.m Ewfifl
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`
`
`me7‘1'fifia'fiwgh-F '
`Irr: 13??
`
`Uncompreased
`
`253’ 36:20:19 10:21:23
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`Fade In DSHH
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`Imagesize:5|2::512
`View EiZE‘Z 5L“) :4 jUD
`WL: 90 WW:
`17”}?!
`
`VIII ?2y,?1y3
`Angogram-JLIHHF] — urnamed
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`Made In DSiPiH
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`In'agr} aim: Eiii .3: 36.51.36
`View size: 805 3: E06
`W;
`iUE’J WW: 21L]
`
`'.-"='.1-
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`..
`
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`151?. 3;
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`Angiogram-PCH‘JEW] ------ Lirmarred
`EEULJIU'Q
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`?r‘r'1r‘r‘r 1'31??? Afigip- I”
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`11.1.I_1_:_;_:rgi_1;: {53.311111133331131
`
`-;":f'-.;-1;:'111.111111HE =|;|]||11.‘g;—;:-
`
`1111.1 L111-211
`'-
`..—-x
`_-.
`_.__.-'.
`I
`| 3'
`
`5571
`
`(SF (5-in-6)
`
`6F II). E 0.0?0”
`
`0.056”
`
`(1.78111111)
`
`(1.42111111)
`
`
`
`5572
`
`113 (6-in—1)
`
`7F ID. 3 GETS“
`
`0.062”
`
`(138111111)
`
`(1.5?111111)
`
`5573
`
`8F (1-in—3)
`
`8F ID. 1“: {1088”
`
`0.0T1”
`
`(224111111)
`
`(130111111)
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`Conclusions
`
`
`
`The Guideliner offers the ability to
`“change course midstream” due to its
`rapid exchange nature as well as allow
`for staged anchoring and extremely
`safe deep cannulation
`
`Multiple techniques can be used in
`isolation or in combination to maximize
`
`and optimize guide catheter support to
`deal with most limitations
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`Conclusions
`
`
`
`the expansion of the transradial
`approach to almost every scenario
`faced in daily coronary practice
`
`The combination of Sheathless
`
`catheters (6.5F and 7.5F) and 5 in 6
`and 6 in 7 Guideliners allows for
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