TORTUOUS VESSEL PCITips and tricks

DEFINITION OF TORTUOSITY

Two or more bends ≥75◦ proximal to the target lesion, at least one proximal bend ≥90◦, or the presence of “significant” vessel curvature proximal to the target lesion.

On the basis of the number of 45◦ bends no/mild = 0–1 moderate = 2 bends severe = 3 or more bends

Manual Interv Cardiol 2002. 237–243.

PASSIVEACTIVE

MOTHER AND CHILDPROXIS

ATRIAL BRANCH

DISTAL RCA

TIPS AND TRICKS!!

Shorter and thin-strut stents (such as cobalt chromium)are more flexible and as a result more deliverable

Shorter and lower profile balloons and stents may be more likely to cross tortuous coronary segments

“Anchor” technique, in which a balloon is inflated in a non target vessel and supports the guide catheter while another balloon is advanced through the main vessel lesion

Stiffer wires lead to more spasm of arteries , at times leading on to significant complications and pseudolesions

Advancement of microcatheters , inflated buddy balloons and telescopic guide system for tortuous vessels

The Hi-Torque Wiggle wire (Abbott Vascular) is a wire with a sinusoidal segment proximal to its tip which can deflect the tip of the balloon or the stent and allow delivery past tortuous or calcified coronary segments but requires larger guide and difficult to pass stent.

Although rapid-exchange devices may be faster and easier to use, over-the-wire devices may have better trackability and deliverability across tortuous segments.

However, use of over-the-wire devices may be associated with longer procedure time and higher radiation

Laser or rotablator may be best avoided in tortuous arteries to prevent serious complications, such as perforation

Deep guide intubation(>20 mm in ostium) carries the risk of pressure dampening, compromising blood flow leading to ischemia and causing coronary dissections

BUDDY WIRE

Use of a ‘‘buddy wire’’ technique was originally described by Selig. Cathet Cardiovasc Diagn 1992;25:331–335.

USES:- The reduction of balloon slippage during angioplasty for in-stent

restenosis; Insufficient back-up of the guiding catheter Stenting of lesions located in vessels with proximal

tortuosities/angulations Stenting of lesions distally located in the vessel Facilitation in the positioning of distal protection devices Stenting of a lesion distally located from a previously implanted stent

or from a coronary segment with both calcification and sharp bend PCI on coronary arteries with anomalous origin.

Burzotta F et al J Invasive Cardiol. 2005 Mar;17(3):171-4.

“BUDDY IN JAIL”

Catheterization and Cardiovascular Interventions 74:564–568 (2009)

MAGNETIC NAVIGATION SYSTEM

The Stereotaxis Niobe1 II MNS (Stereotaxis, St. Louis, MO) has two permanent adjustable magnets that can be rotated, translated, or tilted to produce a uniform magnetic field of 0.08 T.

This field precisely directs a tiny magnet mounted on the tip of a guidewire by changing its’ magnetic moment and allows fine control of the orientation of the tip of the guidewire in space.

The system is integrated with a modified C-arm flat-panel detector fluoroscopic imagingsuite for angiographic imaging.

Catheterization and Cardiovascular Interventions 70:662–668 (2007

THANK YOU