tips and tricks for pci success - promedica international · excellent support simultaneous...
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![Page 1: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/1.jpg)
SCRIPPS CLINIC
Tips and Tricks for PCI Success
Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I. Director, Peripheral Interventions
Program Director, Interventional Cardiology Fellowship
Division of Cardiology
Scripps Clinic
La Jolla, CA
![Page 2: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/2.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 3: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/3.jpg)
SCRIPPS CLINIC
Radial vs. Femoral in 2017
• Radial “first” strategy:
Patient comfort
Less bleeding
Same day discharge, even post-PCI
No need to tie up staff for groin holds
Associated with lower overall cost
• Femoral access for:
Complex anatomy
Extreme tortuosity, calcification, multiple previous stents, CTOs
Need for hemodynamic support device
Known radial/brachial/subclavian tortuosity or arteria lusoria
![Page 4: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/4.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 5: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/5.jpg)
SCRIPPS CLINIC
What Guide Should I Use?
• 6 French system: Most radial cases
Can place 2 simultaneous balloons but not 2 simultaneous stents
Rotablator up to 1.5mm burr
• 7 French system: If you must place simultaneous stents
Rotablator up to 1.75mm burr
• 8 French system: Excellent support
Simultaneous balloons/stents
Rotablator up to 2.0mm burr
1.25mm 1.5 mm 1.75 mm 2.0 mm
6 Fr 7 Fr 8 Fr
Left Coronary: XB guides
Right Coronary: JR4, AL1, or AL 0.75
Use side holes for RCA guides to minimize pressure dampening
![Page 6: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/6.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 7: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/7.jpg)
SCRIPPS CLINIC
Managing Tortuous Vessels
• Use Wholey/Versacore wire (with an appropriately
sized bend) inside JR4 to navigate up iliacs or radial,
then exchange for Amplatz wire
• From femoral approach use a long braided sheath (ie:
Arrow) with a guide catheter 1 French size smaller
Less friction in system
Easier to torque
• Can’t Torque Catheter?
Use 0.63 wire or Amplatz and engage
with wire in guide for support
Keeps guide from kinking
Improves torqueability
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SCRIPPS CLINIC
Correct Bend is Critical! “Spin” Wire As You Advance
Radial Bend
Femoral Bend
![Page 9: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/9.jpg)
SCRIPPS CLINIC
PROBLEM:
Very calcified
radial artery
Sheath wont
advance!
More common in
patients with renal
failure, DM, very
elderly
![Page 10: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/10.jpg)
SCRIPPS CLINIC
SOLUTION:
Angioplasty of
radial artery with
appropriately sized
balloon
6Fr sheath=2.5mm
balloon
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SCRIPPS CLINIC
PROBLEM:
Guide catheter
wont advance
SOLUTION:
Balloon-assisted
tracking through
diseased/tortuous
segments in the
arm
6Fr guide=2.5mm
balloon partially
inside guide
inflated to nominal
creates “torpedo”
![Page 12: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/12.jpg)
SCRIPPS CLINIC
PROBLEM:
Guide catheter
wont advance
SOLUTION:
Balloon-assisted
tracking
6Fr guide=2.5mm
balloon partially
inside guide
inflated to nominal
creates “torpedo”
![Page 13: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/13.jpg)
SCRIPPS CLINIC
PROBLEM:
Guide catheter
wont advance
SOLUTION:
Balloon-assisted
tracking
6Fr guide=2.5mm
balloon partially
inside guide
inflated to nominal
creates “torpedo”
![Page 14: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/14.jpg)
SCRIPPS CLINIC
PROBLEM:
Guide catheter
wont advance
through previous
subclavian stent
SOLUTION:
Balloon-assisted
tracking
![Page 15: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/15.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 16: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/16.jpg)
SCRIPPS CLINIC
I Can’t Engage the Coronary!
• I can engage it with a diagnostic catheter, but not with a guide! Engage with diagnostic catheter, then wire coronary with stiff/supportive wire and then exchange carefully for a guide
• I can see the coronary, but I cant directly engage it with a diagnostic catheter or guide! Make a custom guide using a heat gun or “free wire” the coronary and then use guide extension catheter
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SCRIPPS CLINIC
Heat Gun
•Gently focus heat in area to be
bent
•Avoid melting catheter!
•Avoid burning yourself!
•Quickly dip into flush bath to
cool it and “freeze” shape
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SCRIPPS CLINIC
•Anomalous LCX
![Page 19: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/19.jpg)
SCRIPPS CLINIC
•Diseased
anomalous LCX
•Where exactly
does it come off?
![Page 20: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/20.jpg)
SCRIPPS CLINIC
•Posterior takeoff
very close/shared
with RCA
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SCRIPPS CLINIC
•PROBLEM:
•JR4 will engage,
but dives deeply
past LCX every
time
•Guidewire
inserted into RCA
to help stabilize
JR4
![Page 22: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/22.jpg)
SCRIPPS CLINIC
Custom Multi-Purpose Guide
•Tip partially bent so as not to
engage too deeply into RCA
![Page 23: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/23.jpg)
SCRIPPS CLINIC
•Grandslam
inserted into RCA
via JR4 and then
JR4 exchanged out
for custom guide
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SCRIPPS CLINIC
•SOLUTION:
•Custom guide sits
at the ostium of
RCA and does not
dive too deeply
into RCA
•Allows LCX to be
wired with
hydrophilic wire
![Page 25: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/25.jpg)
SCRIPPS CLINIC
•Anomalous RCA
•NSTEMI culprit
vessel
•Extremely
tortuous iliac
system and
ascending aortic
aneurysm
•Multiple catheters
used in an attempt
to engage RCA
•This is the closest
to engagement…
![Page 26: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/26.jpg)
SCRIPPS CLINIC
PROBLEM:
Can see the
coronary, but can’t
engage it with any
available catheter
shape….
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SCRIPPS CLINIC
•SOLUTION:
•Change to left
radial approach
•Create custom
guide
•Engage with “Free
Wire” technique
![Page 28: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/28.jpg)
SCRIPPS CLINIC
•Pilot 50 wire used
to “Free Wire”
vessel carefully
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SCRIPPS CLINIC
•Corsair catheter
successfully
advanced into
distal vessel
•Pilot 50
exchanged
through Corsair for
a Wigglewire for
improved
deliverability
![Page 30: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/30.jpg)
SCRIPPS CLINIC
Stent advanced
across lesion
![Page 31: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/31.jpg)
SCRIPPS CLINIC
Final Results
![Page 32: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/32.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 33: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/33.jpg)
SCRIPPS CLINIC
I Can’t Deliver Balloon or Stent!
• Wiggle Wire
• Guide Extension Catheter
• Buddy Wire
• Buddy Balloon Non-inflated
Inflated: “Anchor Balloon”
• Use multiple shorter stents
• Rotablator to modify calcium
• Combinations of the above
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SCRIPPS CLINIC
Wiggle Wire:
How Does it Work?
Contact of wiggles
with vessel walls
provides friction and
distal anchoring
Wiggles change
relative angle of
device to lesion
and vessel
![Page 35: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/35.jpg)
SCRIPPS CLINIC
Proper Use of Guide Extension
Catheters
•“Torpedo” Technique
•“Inchworm” Technique
•“Anchor” Technique
•“Unsheathing” Technique
![Page 36: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/36.jpg)
SCRIPPS CLINIC
“Torpedo Technique”
6Fr guide extension
catheter with 2.5mm
compliant balloon
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SCRIPPS CLINIC
Guide Extension Catheters: Game Changing Technology
• “Variable Guide” technique
Can use with a less supportive guide (ie: JR4)
and used to vary support for distal vs. proximal
interventions
• Often use 6Fr inside a 7Fr or 8Fr guide
Can pass 6Fr guide extension catheter deeper
into vessel
Allows better guide support
• Can also be used to minimize contrast
exposure
![Page 38: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/38.jpg)
SCRIPPS CLINIC
Variable Guide Technique
![Page 39: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/39.jpg)
SCRIPPS CLINIC
PROBLEM:
Patient with LAD
lesion post-
Corevalve, can’t
engage the
coronary with a
guide!
![Page 40: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/40.jpg)
SCRIPPS CLINIC
SOLUTION:
Use JL4 diagnostic
catheter to enter
correct strut
Insert Grandslam
wire
Carefully remove
diagnostic catheter
and insert guide
catheter
![Page 41: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/41.jpg)
SCRIPPS CLINIC
BAT used to
advance 6Fr XB3.0
guide from right
radial approach
over Grandslam
wire
![Page 42: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/42.jpg)
SCRIPPS CLINIC
PROBLEM:
XB Guide wont
directly engage the
coronary due to
Corevalve frame
and subclavian
tortuosity
![Page 43: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/43.jpg)
SCRIPPS CLINIC
SOLUTION:
6Fr guide
extension catheter
![Page 44: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/44.jpg)
SCRIPPS CLINIC
Guide extension
catheter inserted
through Corevalve
frame into LM and
lesion treated
![Page 45: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/45.jpg)
SCRIPPS CLINIC
Final Results
![Page 46: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/46.jpg)
SCRIPPS CLINIC
PROBLEM:
Cant deliver stent
into anomalous
circumflex
SOLUTION:
6Fr guide
extension catheter
inserted via
“Inchworm
Technique”
![Page 47: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/47.jpg)
SCRIPPS CLINIC
Guide extension
catheter withdrawn
to expose next
area to be stented
![Page 48: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/48.jpg)
SCRIPPS CLINIC
Second stent
positioned and
deployed
![Page 49: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/49.jpg)
SCRIPPS CLINIC
Final results
![Page 50: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/50.jpg)
SCRIPPS CLINIC
•Tortuous RCA
•Distal lesion
•AL1 deep-seated
into RCA
PROBLEM:
•Stent will not get
past mid RCA due
to tortuosity
![Page 51: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/51.jpg)
SCRIPPS CLINIC
SOLUTION:
“Anchor Balloon”
Technique
•Buddy wire
advanced into
distal RCA
•2.75mm compliant
balloon advanced
over buddy wire
into distal RCA and
inflated
•Stent can now be
advanced over first
wire into distal
RCA
![Page 52: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/52.jpg)
SCRIPPS CLINIC
•Buddy wire and
balloon then
removed
•Stent positioned
across lesion and
deployed
![Page 53: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/53.jpg)
SCRIPPS CLINIC
Final Results
![Page 54: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/54.jpg)
SCRIPPS CLINIC
Tortuous RCA with
proximal, mid, and
distal disease
![Page 55: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/55.jpg)
SCRIPPS CLINIC
“Variable Guide”
Technique
•8Fr Long Arrow
braided sheath with
7Fr JR4 guide
•6Fr guide extension
catheter
•Pilot 50 exchanged
for Wiggle Wire
![Page 56: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/56.jpg)
SCRIPPS CLINIC
•Shorter stent used
because longer
one wouldn’t track
“Amplatzification”
of JR4 guide with
guide extension
catheter
![Page 57: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/57.jpg)
SCRIPPS CLINIC
Second shorter
stent advanced
![Page 58: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/58.jpg)
SCRIPPS CLINIC
Guide extension
catheter retracted
back to address
mid/prox disease
![Page 59: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/59.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 60: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/60.jpg)
SCRIPPS CLINIC
It’s Not a CTO but…
I Can’t Wire This Vessel!
• Wire won’t torque or prolapses?
Use an OTW system for support
Hydrophilic wires torque easier and cross calcified/tortuous
lesions easier
BUT can also “get behind” plaque easier and cause vessel
closure/dissection
• Extreme tortuosity?
Venture catheter
• Severe disease/dissection?
Careful use of hydrophilic soft wires
Use of the “progressive true lumen” approach
![Page 61: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/61.jpg)
SCRIPPS CLINIC
•NSTEMI
•Tortuous iliacs
long 8Fr sheath with
7Fr guide
•Graft to LAD closed
•Severe native LAD
lesion
![Page 62: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/62.jpg)
SCRIPPS CLINIC
•35 mins of fluro
spent trying to wire
LAD….
•Wires successfully
inserted into septal
and diagonal, but not
LAD!
•Poor flow and
?dissection in LAD
![Page 63: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/63.jpg)
SCRIPPS CLINIC
•Further attempts to
wire LAD are
unsuccessful- wires
go into dissection
plane
•Decision made to
balloon ostium of
septal across
ongoing LAD with 2.0
mm balloon
![Page 64: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/64.jpg)
SCRIPPS CLINIC
•Wire partially
inserted into LAD,
but not free and
appears to be in
dissection plane
![Page 65: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/65.jpg)
SCRIPPS CLINIC
•Wire left in LAD
dissection plane
•Fourth wire
advanced into small
septal branch that
comes off LAD
downstream of the
large first septal
branch
•Small septal dilated
with 1.5mm balloon
![Page 66: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/66.jpg)
SCRIPPS CLINIC
•Small septal comes
off true lumen of LAD
just downstream of
large first septal
•OTW balloon
advanced into small
septal branch and
wire exchanged for
hydrophilic wire with
90 degree bend
![Page 67: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/67.jpg)
SCRIPPS CLINIC
•After hydrophilic
wire advanced into
true lumen of distal
LAD, OTW balloon
advanced and wire
exchanged for
Wiggle Wire
•Balloon angioplasty
of and stenting of
LAD performed
![Page 68: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/68.jpg)
SCRIPPS CLINIC
Final results
![Page 69: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/69.jpg)
SCRIPPS CLINIC
“Progressive True Lumen Approach”
Target Vessel
Can’t pass
wire due to
dissection or
plaque
Wire small
sidebranch
off true lumen
Dilate into
sidebranch
and exchange
wire for 90
degree bend
or angled
catheter
Carefully
redirect wire
into true
lumen
Dilate and
stent into
target vessel
#1
#2 #3 #4
![Page 70: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/70.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 71: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/71.jpg)
SCRIPPS CLINIC
Uh Oh… I Have a Perforation!
• Good practice to take a small “puff” after a balloon
is deflated to be sure there is no perforation
• If perforation noted, FIRST thing to do is re-insert
balloon and tamponade the bleed
• Consider reversing heparin with protamine, stop
Angiomax
• JoStents can be very difficult to deliver!
Get second access- VERY important!
Leave balloon up from first guide while second guide is
positioned
“Dueling Guide” technique
![Page 72: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/72.jpg)
SCRIPPS CLINIC
LAD stent deployed
![Page 73: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/73.jpg)
SCRIPPS CLINIC
Uh oh….
•Fortunately, balloon
still in place
•Immediately inflate
balloon to
tamponade bleeding
![Page 74: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/74.jpg)
SCRIPPS CLINIC
•Balloon left up while
second access
obtained with 8Fr
guide
•Second guide
brought into position
•Wire from second
guide brought down
to balloon, balloon
quickly deflated, wire
passed, then balloon
reinflated
![Page 75: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/75.jpg)
SCRIPPS CLINIC
•JoStent advanced
into prox LAD
•Balloon deflated and
quickly withdrawn
into guide and
JoStent quickly
advanced into
position
![Page 76: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/76.jpg)
SCRIPPS CLINIC
•Jostent deployed
![Page 77: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/77.jpg)
SCRIPPS CLINIC
Perforation sealed
![Page 78: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/78.jpg)
SCRIPPS CLINIC
Common PCI Challenges
•Choosing the correct vascular access site
•Choosing the correctly sized guide catheter
•Unable to navigate from access point to the heart
•Unable to properly engage coronary ostium
•Unable to deliver balloons or stents
•Unable to wire a non-CTO lesion
•Coronary perforation
•Stent underexpansion
![Page 79: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/79.jpg)
SCRIPPS CLINIC
I Have Stent Regret!
• I deployed a stent, but now it wont expand!
High pressure balloon inflation Chocolate Balloon
Laser technique Use 0.9mm laser catheter with contrast infusion rather than saline
(OFF LABEL!)
Set to 80/80 on settings
![Page 80: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/80.jpg)
SCRIPPS CLINIC
•Distal RCA disease
![Page 81: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/81.jpg)
SCRIPPS CLINIC
•Lesion seems to
expand with 2.75mm
balloon
![Page 82: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/82.jpg)
SCRIPPS CLINIC
•3.0mm stent
deployed to 18 Atm
![Page 83: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/83.jpg)
SCRIPPS CLINIC
•Second 3.0mm stent
deployed just
proximally
![Page 84: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/84.jpg)
SCRIPPS CLINIC
•3.25mm non-
compliant balloon to
30 Atm!!
PROBLEM:
•Stent wont expand
![Page 85: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/85.jpg)
SCRIPPS CLINIC
SOLUTION:
•0.9mm laser
catheter set to 80/80
•Contrast infused
rather than saline
![Page 86: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/86.jpg)
SCRIPPS CLINIC
•Expands now with
3.25mm non-
compliant balloon!
![Page 87: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/87.jpg)
SCRIPPS CLINIC
•2.5mm stent at PDA
ostium
![Page 88: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/88.jpg)
SCRIPPS CLINIC
Final Results
![Page 89: Tips and Tricks for PCI Success - Promedica International · Excellent support Simultaneous balloons/stents Rotablator up to 2.0mm burr 1.25mm 1.5 mm 1.75 mm 2.0 mm 6 Fr 7 Fr 8 Fr](https://reader034.vdocuments.mx/reader034/viewer/2022043008/5f99b1bbb94f2b29793e15bc/html5/thumbnails/89.jpg)
SCRIPPS CLINIC
Thank You