Κερκιδικήπροσπέλαση. Πότε και πως; X. Γραΐδης Επεμβατικός καρδιολόγος, FSCAI Κλινική Εuromedica«Κυανούς Σταυρός», Θεσσαλονίκη - PDF

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Κερκιδικήπροσπέλαση. Πότε και πως; X. Γραΐδης Επεμβατικός καρδιολόγος, FSCAI Κλινική Εuromedica«Κυανούς Σταυρός», Θεσσαλονίκη Femoral Complication Waiting to Happen!!! In 1989 Lucien Campeau attempted

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Κερκιδικήπροσπέλαση. Πότε και πως; X. Γραΐδης Επεμβατικός καρδιολόγος, FSCAI Κλινική Εuromedica«Κυανούς Σταυρός», Θεσσαλονίκη Femoral Complication Waiting to Happen!!! In 1989 Lucien Campeau attempted the first radial artery approach to cardiac catheterization, postulating that this approach would prove free of significant vascular complications, primarily because the hand has collateral circulation and the cannulationsite is devoid of nerves or veins of significant size. The first elective percutaneouscoronary intervention via the TRA was performed in 1992 by Ferdinand Kiemeneij In 1995, Kiemeneijet al conducted a study on transradialartery angioplasty using 6F introducer sheaths with new 6F guiding catheters. In 100 patients with collateral blood supply to the right hand, PTCA was attempted using 6F guiding catheters and rapid exchange balloon Angiography of normal radial, ulnar, and brachial artery radial artery brachial artery 77-85% of subjects Ulnar artery Interosseous artery The radial artery originates from the brachial artery below the elbow crease and passes on to the lateral aspect of the forearm, traveling to the wrist. The radial artery runs under the supinatorlongusmuscle in the upper part of the forearm, continuing between the tendons of the supinatorlongusand the flexor carpiradialismuscles of the forearm to the wrist. At the wrist, the radial artery lies on top of the scaphoidbone, the trapezium and the external lateral ligament. Because of the downward course of the radial artery after the scaphoidbone, the artery is difficult to canulateunless one enters 2-3 cm more proximal to this site. The radial artery is relatively superficial, allowing easy identification and puncture of the artery. is easily compressible there are no important nerves running along side of it, and There is dual supply making the puncture and compression relatively safe The radial artery passes between the metacarpal bones of the thumb and index finger into the palm, crossing the base of the 5th metacarpal bone, and joining the deep communicating branch of the ulnarartery, forming the deep palmararch. The superficialisbranch of the radial artery joins with the palmarportion of the ulnarartery to complete the superficial palmar arch. Variations of the Superficial PalmarArch A. Typical radioulnar communication (35%). B. Formation of complete arch by the ulnarartery (39%). C. Completion of arch by ulnar and median arteries (4%). D. Joining of ulnar, median, and superficial branches of the radial artery (1%). E. Incomplete arch; formation of the proper digital arteries by the radial and ulnararteries without communication between the radial and ulnar arteries superficially (16%). F. Contribution of ulnar, median, and superficial branches of the radial artery to the digital vessels, without communication between the branches at the superficial level (5%). Allen s Test Shows Intact Palmar Arch The risk of transient or permanent radial artery occlusion with a normal Allen s test is 5.3% and 2.8% respectively. Therefore, it is advisable to confirm a dual arterial supply to the hand (Allen s test) But, an abnormal Allen s test has never been predictive of ischemic injury from an arterial line Unilateral Absence of the PalmarArch Without Collateral Circulation Modified Allen s test Oxymetry + Plethysmography Modified Allen s test Barbeau et al. Am Heart J 2004;147: Type D is associated with an incomplete palmararch and radial catheterisation should not be performed. Arm is very well collateralized But, an abnormal Allen s test has never been predictive of ischemic injury from an arterial line No correlation to hand ischemia & arterial lines Extensive radial CABG experience without ischemia Radial harvest with abnormal Allen s Test is possible# Hand ischemia from transradialprocedures has not been a problem despite a 15 year experience Why Radial? The Advantages Decreased incidence off major entry--site complications Easier vascular access and hemostasis for obese patients Decreased time to ambulation Improved patient movement-satisfaction Decreased post--procedural cost Meta-analysis of 23 RCTs with 7020 patients undergoing coronary diagnostic and interventional procedures Jolly et al. Am Heart J 2009;157:132-40 Radial mega-analysis N=76 studies (15 rand; 61 obs); 761,919 patients Bertrand OF, et. al. AHJ 2012 Among the patients who had both methods, the transradialmethod was strongly preferred in 80% with only 2% preferring transfemoral catheterization Patient Satisfaction Patient prefers assigned access route for next procedure (%) Cooper et al. Am Heart J 1999;138: RIVAL: Jolly SS, et al. Lancet 2011; 377: Why not Radial? The Disadvantages It requires special catheter shapes for coronary cannulationfor more inexperienced operators. It is associated with a physician learning curve. The learning curve is also steeper than for TFA. Small artery size restricts interventional device options. Most TRA procedures are performed with a 5 Fr or 6 Fr system, although 7 Fr access may be possible in larger patients Elderly hypertensive patients may have increased tortuousityof the radial and subclavianarterieswhich makes the procedure more challenging because stiffer guidewires are needed. The rate of crossover from TRA to TFA is significantly higher than that observed for TFA to TRA Radiation exposure Radial vs. Femoral for Radiation Radial vs. Femoral for Radiation Radial vs. Femoral for Radiation Modest difference only in low volume radial operators Radial vs. Femoral for Radiation Experience and how you practice more important than radial vs. femoral Major reductions in exposure are possible: Reduced fluoroscopy time with experience Radial specific shielding Reduction in pulse rates in X- Ray equipment Radial Approach: The learning curve The radial approach has a more significant learning curve, particularly involving arterial access, manipulation across the shoulder, and seating the catheters with sufficient backup for PCI With appropriate training, similar success rates with the radial and femoral approaches may be achieved even in complex cases. Although published data suggest that cases are necessary to become proficient in the TRA, the learning curve is highly individual and more experienced operators may become proficient sooner When to Avoid Radial Access Absolute cons: Absence of RA pulse Ischemic Allen test AV- shunt for hemodialysis Relative cons: A very small RA Pathology of proximal arteries LIMA using RRA RIMA using LRA Left or Right Radial Approach The choice is more or less related to operator preference The RRA seems to be more nurse and doctor friendly Probably LRA is better for slim women with thin, spasm prone arteries esp with subclavian tortuosity and is certainly the choice with -Allen on the right or when a LIMA angiois idicated Left or Right Radial Approach The loop formed in the guide wire due to marked vascular tortuosity in the radial approach (A). No significant vascular tortuosity in the left radial approach (B). How do you educate the staff? Need to learn how to prepare the patient and position the arm How do you educate the staff? There are some subtle, but important, differences in the way staff prepare for a case: A pulse oximetershould be placed on the index finger or thumb of the arm that is being intervened upon. This allows for continuous assessment of the vascular integrity of the radial/ulnar system. The wrist should be adequately cocked to facilitate arterial access. This can be accomplished with either a small, well-rolled gauze or a splint-like device (Accumed Systems, Inc.). The armboardshould allow for access at approximately a 45-degree angle from the patient and then allow the arm/wrist to be placed next to the hip. Conventional drapes are often inadequate. Specialized radial drapes are now available. It is often possible to move a femoral drape over to cover the wrist and the propped groin or to use brachial drapes. Puncture technique Puncture technique Cold is a powerful stimulus for vasoconstriction and keeping the patient warm is important. Local anaesthesiais performed, using 1-2 mlsof lignocaine. This is injected alongside the radial artery. Avoid infiltration of the radial artery, as this will provoke radial artery spasm A small incision can be made in the skin with a scalpel (although this is not always necessary especially with newer low-profile sheaths).the reason for incision is that the skin provides significant resistance to the needle passage and this limits the ability to feel transmitted pulsation as the needle is advanced. Puncture technique Accessing the radial artery with a micropunctureneedle and guide wire is the hardest part of radial access The point of puncture should be2-3 cm cranialtothe bony prominence of the distal radius(left arrow). 2. The transfixation technique Puncture technique 1. The open needle technique The needle should be inserted at a degree angle. There may be only a small flashback as the artery is small. If there is good flow on puncture of the anterior arterial wall the wire can be advanced directly. Gentle rotation of the needle may allow direction of the wire to the true lumen. If there is poor flow or the wire does not pass easily, advance the needle then withdraw slowly until the needle tip is back in the artery lumen and there is good blood flow. This is analagousto using the venous Venflonpuncture technique. The artery is punctured using the transfixationkit. This is advanced through the posterior wall of the artery. The needle is then removed and the catheter withdrawn slowly until there is good blood backflow. When there is a good arterial bleed back from the needle or catheter the guidewire should be gently advanced Puncture technique On occasion the artery will be quite palpable, but difficult to stick. This is often seen in atherosclerotic calcified vessels. This is usually addressed by fixing the radial artery with the left thumb while attempting radial access. Puncture technique-hit it on the first try Optimal Puncture First Hit is the Best The radial artery is prone to spasm and it is not uncommon, after you nick the artery, to notice a diminished (even if transient) pulse. If this occurs, and it appears to be related to spasm, you have several options: Wait Go proximal Give NTG IV or SL (or mcg of SQ NTG over the artery) Have the patient clench/open the hand Go to another site Hit it on the first try-spasm from failed access Subcutaneous nitroglycerin administration leads to faster re-establishment of radial pulse compared with sublingual adiministration Difficult Guide Wire Movement-The Wire is a Friend : Don t Push The second major point of difficulty is advancing the guide wire. After successful access is achieved it is sometimes difficult to advance the guide wire. The differential diagnosis includes: Tortuosity Spasm Radial is occluded Guidewireis in a side branch (usually too distal in the artery) Abnormal take off of the radial (off of the brachial) Radial artery stenosis Against the wall or subintimal Difficult Guide Wire Movement-The Wire is a Friend : Don t Push If this situation occurs, the following options should be tried: Rotate the needle to change the angle of the bevel retract the wire, spin it gently and try again. Retract the wire and apply a small bend, and re-introduce it. Use a hydrophilic-coated wire Try a PTCA wire Give vasodilators through the needle and then try to advance wire Do a radial angiogram re-puncture more proximally. These maneuvers must be done relatively quickly, as clotting in the micropuncture needle will occur within 4 minutes without anticoagulation. TransradialMedications The radial artery can be subject to rather intense spasm which can be painful to the patient and make sheath and catheter movement difficult. Antispasm: Before catheter insertion, most operators administer 2.5 to 5 mg of verapamilwith or without 100 to 200 μgof nitroglycerin (diluted in 10 ml saline) directly into the RA through the side arm sheath. Dilution of medication in blood reduces burning in the hand. At the same time, heparin at a dose of at least 50 u/kg (or 3,000-5,000 U) is given intravenously for prevention of RA occlusion Selection of inch Guide wire. Amplatz stiff inch GW(Left). Hydrophilc-coated inch GW Standard inch GW(right). Measures to take when the wire enters only to the descending aorta If the J-wire passes repeatedly to the descending aorta, ask the patient to take a deep breath in while gently rotating the catheter anticlockwise. This straightens the mediastinalvessels and helps avoid the descending aorta. Panel A: During expiration there is a more acute angle (α) between the brachiocephalic trunk and the ascending aorta, therefore the wire takes a more horizontal a more horizontal direction towards the descending aorta. Panel B: During deep inspiration, the diaphragm lowers the heart and straightens the angle (α) between the brachiocephalictrunk and the ascending aorta. The wire takes a more vertical direction towards the ascending Measures to take when the wire enters only to the descending aorta Manipulate using LAO 45o view. JR will probably be the easiest alternative a. Drop the wire into the descending aorta and advance catheter along it b. Remove the wire with catheter tip in aortic arch. Have the patient take a deep breath and rotate the catheter counterclockwise. c. Face the catheter tip toward the ascending aorta and advance the wire Catheter selection and technique List of catheters which have been proposed for the TRA Catheter selection and technique Standard diagnostic catheters can be used for the left radial approach. However, for the right radial approach, the JudkinsLeft 3.5instead of the JL 4 is often used to engage the left coronary ostiumand the JudkinsRight 4 for the right coronary ostium Sometimes alternative catheters (with varying sizes) may be used e.g., Amplatz left/right. Catheter selection and technique There are also dedicated radial catheters available (Barbeau, Kimny, Tiger, etc.); These can be used to engage the left and right coronary ostia with one catheter Single vs Double Catheter Technique Single vs Double Catheter Technique Anticipated Advantages Less procedural and fluoroscopy times Reduction of risks related to catheter exchange (spasm, emboli, air) Loss of catheter position esp. with difficult anatomy Cost-effectiveness Catheter selection and technique Anatomic variants are common, and just as with femoral catheterization, no single catheter will be successful in every case. It is important to recognize this early and switch to an alternative catheter shape, if needed. Catheter selection and technique Selective LIMA Injection Via the Right Radial Approach The catheter is rotated counterclockwise and pointed toward the left subclavian. The wire is advanced distally and then the catheter. The wire is removed, and the catheter is pulled back to selectively engage the left internal mammary. Selective LIMA Injection Via the Right Radial Approach Selective engagement of LIMA graft can be done with the use of special catheter such as a modified Simmons catheter Selective LIMA Injection Via the Right Radial Approach Limitations of engaging the LIMA via the right radial artery may include: subclaviantortuosity, a vertical aorta, and patients with known severe atherosclerotic disease of the aortic arch. Catheter selection and technique :Tips & Tricks Smart use of small tricks makes a big difference Catheter selection and technique :Tips & Tricks Get a feel for the catheter : To accomplish the coronary cannulationusing TRA, form a habit of using your fingers and not the wrist TRA necessitating small (finger-based) clockwise and counterclockwise torquing movements and active catheter holding Catheter selection and technique :Tips & Tricks Removing the catheter after the angiogram should be done over the J-wire. This prevents damage to the artery and reduces the rate of arterial occlusion. The wire also prevents the tip of the catheter lodging in other arteries. A long exchange wire can be used The tip of the J-wire must be visualisedat all times during withdrawal and advancement of the catheter. Variations of the radial artery In routine clinical practice, variations of the radial artery are the main reason for technical failures in transradial catheterization. In order to help proper identification of the anatomy and to avoid traumatic manipulation of guide wire, early angiography is clearly needed. Variations of the radial artery Variations of the radial artery: Radial high take-off Often remains unrecognized during diagnostic angio. Not a significant cause of procedural failure ( %) RADIAL LOOP WITH RADIAL RECURRENT ARTERY THE MOST IMPORTANT ANATOMICAL VARIATION: Slender Radial Artery type 3 ( 1%) Type 3 is associated with radial access failure. In this variation, the remnant radial artery with a small arterial diameter cannot be catheterized and is very prone to developing a spasm Radial artery loop The radial loop is the most common anomaly of the radial artery and it occurs in 1-2% of patients. Most common cause of failure ( %) Variations of anastomosis between brachial and radial or ulnar artery Technique to overcome extreme radial artery tortuosity Extreme radial artery tortuosity was not infrequently seen in elderly patients hypertension and history of heavy smoking. The presence of extreme radial tortuosity was also associated with a high procedural failure rate. These vessels were prone to severe radial artery spasm Technique to overcome extreme radial artery tortuosity Meticulous manipulation is needed for advancing a guidewireor catheter. For the most part, guide wire approach is difficult to advance to the brachial artery. Never push the guide wire and take a radial angiogram via a radial sheath. Under the fluoroscopic guidance, inch hydrophilic guide wire (Terumo, Japan) rather than Teflon coating conventional guide wire is advanced carefully toward the brachial artery. Technique to overcome extreme radial artery tortuosity Backup of conventional guide wire. After advancing guide wire under the fluoroscopic monitoring, the operator should push the angio-catheter carefully until the brachial loop is straightened. Technique to overcome extreme radial artery tortuosity To overcome tortuosity, use conventional 0.014 standard coronary wire. A balloon passed over the angioplasty coronary guidewirecan provide extra support and allow advancement of the guiding catheter if required Extreme aortic tortuosity Subclavian tortuosity (ST) occurs in up to 10% of patients Clinical predictors: Hypertension Older age Short stature Female gender obesity Extreme aortic tortuosity Recent data have confirmed that patient height and age are risks for procedure failure, with the highest failure rates occurring in patients 165 cm tall and older than 75 years. Technique to overcome extreme aortic tortuosity Asking the patient to take and hold a deep breath can be useful while advancing or manipulating the catheter Technique to overcome extreme aortic tortuosity Thicker wire Accommodate thicker or stiffer wire, by which a tortuous vessel will straighten and a guiding catheter will get enough support and lower resistance (with extreme caution to avoid perforation of damage to the vessels) Change to Smaller Size Catheter Downsizing of the catheter might decrease resistance and help achieve successful PCI without access-site crossover Technique to overcome extreme aortic tortuosity For TRI where a small diameter catheter alone has to cope with tortuosity in the brachio-cephalic artery, the wire, as a rule, should be left in the catheter to prevent kinking until the catheter is engaged in the coronary artery. In the case in the RCA where the catheter has to be rotated or the use of 5 F
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