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07 aimradial2016 fri2 P Montorsi

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Use of radial access for carotid interventions with protection device, P Montorsi

Publicado en: Salud y medicina
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07 aimradial2016 fri2 P Montorsi

  1. 1. Use of radial access for carotid interventions with protection device Piero Montorsi, MD Associate Professor of Cardiovascular Diseases Department of Clinical Sciences and Community Health, University of Milan Director, 2nd dep’t Invasive Cardiology Centro Cardiologico Monzino, IRCCS, Milan, Italy
  2. 2. Speaker name: Piero Montorsi, MD Consultant for Boston Scientific, Medtronic
  3. 3. CAS through radial/brachial approaches Is it a safe & effective technique? N=382 2012 N=260 2014 We… can… do it !!
  4. 4. RSA-RCCA (TRA) IA-LCCA (TRA) Sharp angle + lack of anatomic support + CAS through the transradial approach Why a difficult technique? device stiffness = high rate of failure
  5. 5. Transradial/brachial CAS The Monzino’s experience 0 15 30 45 60 75 90 105 120 ’00 02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 TR/TBA/TU 267/926 (29%) CASprocedures/year(n) N=1197 ‘15 TR/TB/TU w Filter (n=191, 84% radial) TR/TB w Mo.Ma (n=76, 55% radial) 6/’16 66% (34/51 pts) 73%
  6. 6. Transradial/brachial CAS with proximal protection Patient population ‘close-up’  Number of pts: 76/267 (28.4%)  Indications: - Symptomatic pts - Asymptomatic pts with high risk clinical and or anatomic characteristics  Vascular access: - Radial/brachial approach (according to clinical assessment and/or Doppler US)  Type of PP: 8F Mo.Ma (Medtronic)  Type of stent: 5F-compatible stents  Anticoagulantion: Heparin (TR), Bivalirudin (TB)  Closure: TR-band+’patent’ hemostasis (TR) and manual compression (TB)
  7. 7. 6F Sheath (Avanti, Cordis) 11 cm OD: 2.67mm ‘6F in 5’ (GSS, Terumo) 10 cm OD: 2.46mm + GC 6F + CW7/Precise 8 Roadsaver (any size) 8F Sheath Avanti (Cordis) OD: 3.3 mm 11 cm5.5 cm CAS with Mo.Ma (8F)CAS with filter Radial artery cannulation
  8. 8. RSA-RCCA Bifurcation (+ RICA stenosis) LCCA take off from the aortic arch (+ LICA stenosis) TR/TB CAS with proximal protection Technical success/failure rate LCCA take off from the IA: BAAC (+LICA stenosis) First attempt failure rate 26/75 (34.6%) 0% 40% 80%Technical success 75/76 (98.6%) Crossover rate: 1.3%
  9. 9. TR/TB CAS with proximal protection LICA lesion in BAAC Type 2 bovine aortic arch + LICA stenosis. CT-angio (LAO 45° view) 5F diag RJ in LCCA through right brachial artery 8F MO.MA system ECA+CCA balloons occlusion (arrows) Final result CW (7x30), post- dilated with a 5.5x20mm
  10. 10. TR CAS technical failure Sharp angle between RSA-RCCA bifurcation RICA stenosis Right radial approach Attempt to position the Mo.Ma system over a .035’’ stiff wire (Supracore)  prolapse into the IA
  11. 11. Transradial CAS with proximal protection The No.MA2 technique 26/75 (34.6%) ‘first attempt’ failure  Reduce the device stiffness  1. Mandrel removal (5-10cm) and try again
  12. 12. Transradial CAS with proximal protection The No.MA2 technique TS: 1/26 (3.8%)
  13. 13. Transradial CAS with proximal protection The No.MA2 technique 0.035” Emerald wire loaded into the working channel (mandrel withdrawn) 0.035” stiff wire loaded into the distal port No.Mandrel 2 wires technique (No.MA2 technique) 26/75 (34.6%) first attempt technical failure  1. Mandrel removal (5-10cm) and try againif fails  Improve wire support 
  14. 14. TR CAS technical failure Sharp angle between RSA-RCCA bifurcation RICA stenosis Right radial approach Attempt to position the Mo.Ma system over a .035’’ stiff wire (Supracore)  prolapse into the IA
  15. 15. Sharp angle between RSA-RCCA bifurcation Mo.Ma placement with the No.Ma2 technique-1 6FRJ guide into ECA A second stiff wire was positioned deep into ECA. 6FRJ guide removed The 2 stiff wires loaded into the ECA channel and the working channel, respectively and Mo.Ma system positioned in RCCA Stiff Angled Glide Wire 4MP, 125 cm 6 Guiding cath.
  16. 16. Sharp angle between RSA-RCCA bifurcation Mo.Ma placement with the No.Ma2 technique-2 Cristallo Ideale 7-10x40mm Postdil 5.5x20 Occlusion test8F Mo.Ma in place ECA balloon inflation and test for ECA exclusion Final result
  17. 17. Sharp angle of RSA-RCCA bifurcation Mo.Ma placement with modified technique 78yom. Right hemisphere minor stroke. Right ICA ‘near-occlusion’ Right radial approach 5FRJ cath in RCCA over .035’’ Terumo wire Terumo wire echanged for a .035’’ stiff wire. 5FRJ removed. Failure to advance the 8F Mo.ma device Additional wire in ECA through a coxial system (4FMP125 + 6FRJ guide)
  18. 18. Additional 0.035” Emerald wire below bifurcation through 6FRJ guide ECA Both MO.MA balloon inflated Final result after Cristallo stent 7- 10x40mm Sharp angle of RSA-RCCA bifurcation Mo.Ma placement with modified technique
  19. 19. LCCA LSA IA HU: 34 Left ICA PSV: >4m/s Sharp angle of IA-LCCA bifurcation Mo.Ma placement with the No.Ma 2 technique
  20. 20. Sharp angle of IA-LCCA bifurcation Mo.Ma placement with the No.Ma 2 technique 8F MO.MA in place Coaxial system: 6FRJ guide+4FMP 125, loaded on Terumo wire from R brachial approach 6FRJ 4FMP 125 6FRJ guide in ECA. 4FMP removed Terumo wire exchanged for .035” standard wire + .035”stiff wire (Magic Torque, BSI). 6FRJ guide removed. 8F MO.MA loaded on the 2 wires (No.Ma technique) Final result
  21. 21. Sharp angle between RSA-RCCA bifurcation Mo.Ma placement with the No.Ma2 technique-1 74yom. Recent right hemisphere minor stroke. Type III aortic arch. Failure of CAS by femoral artery. Rescheduled from the right RA approach Early arterial frame Late arterial frame
  22. 22. Sharp angle between RSA-RCCA bifurcation Mo.Ma placement with the No.Ma2 technique-3 .035’’ Emerald .035’’ Magic Torque 5FIM .035’’ Terumo 6FRJ
  23. 23. Sharp angle between RSA-RCCA bifurcation Mo.Ma placement with the No.Ma2 technique-2 OA STA
  24. 24. The No.Ma2 technique Which type for the additional wire? 14 pts: 1 stiff + 1 Emerald wire 7 pts: 2 Emerald wire 2 pts: 2 Stiff wire 1 pt : 1 stiff wire + 1 Terumo wire 1 pt: 1 Emerald wire + 1 V18 wire At least 1 stiff wire in 15/26: 61.5%
  25. 25. Transradial CAS with proximal protection Bifurcation disease: potential issues The ECA occlusion/stenosis:  does not allow positioning of a stiff wire deep into this vessel to support any device advancement (i.e. GC, sheath)  does not allow the use of the standard proximal protection (Mo.MA 8F Ultra)
  26. 26. Up to 205 mm 15 mm 85 mm Standard System set up Y-connector+MO.MA w mandrel System set up variant #1 No Y-connector System set up variant #2 Mandrel exchanged for a 4F 125cm MP Transradial CAS with proximal protection Mo.Ma Ultra mono balloon: Instructions for use-1
  27. 27. Transradial CAS with proximal protection Mo.Ma Ultra mono balloon: Instructions for use-1 The No Mandrel 2 wire technique (The ‘No.Ma2’ technique) Stiff wire 0.035’’ Emerald wire 0.035’’
  28. 28. Type I aortic arch LCCA from the aorta LICA stenosis 1. Right fetal PCA 2. No left PCoA 3. Patent ACoA ICA ECA ICA CCA CCA ECA 1 2 3 Willis circulation Transradial CAS with proximal protection in bifurcation disease
  29. 29. Transradial CAS with proximal protection in bifurcation disease R radial access. 5F Tiger into LCCA  .035” standard wire tip shaping 8F MO.MA mono loaded on the 2 standard wires (No.Ma technique) Additional .035” standard wire through 6FRJ guide 5F Tiger exchanged for coaxial system (6FRJ+4FMP, 125 cm) 6FGC 4FMP CTA (VR) 45°RAO view
  30. 30. Transradial CAS with proximal protection in bifurcation disease CM injection (early to late frame) Spider Rx filter,6 mm CW 7x30 post-dil 5.5x20 Final result74mmHg
  31. 31. TR/TB CAS Radiation exposure TR/B CAS w Mo.Ma (n=61) TR/B CAS w Filter (n=153) P value Fluoroscopy time (sec) 780±361 957±511 0.018 DAP (Gym2) 6884±2964 7252±6052 0.66 Contrast medium (ml) 109±38 135±47 0.0003
  32. 32. Tranradial approach for CAS Role of the learning curve on radiation exposure Source DF Type III SS Mean Square F Value Pr > F Year 1 5,3E+08 5,3E+08 20,19 <.0001 Group 1 4525130 4525130 0,17 0,6793 Source DF Type III SS Mean Square F Value Pr > F Year 1 3,6E+07 3,6E+07 4,35 0,0418 Carotid side 1 3287317 3287317 0,4 0,5297 N=214 N=61Left Right Filter Mo.Ma Filter vs. Mo.Ma/year Right vs. left carotid w Mo.Ma/year
  33. 33. Right TR CAS with Mo.MA for LICA stenosis and BAAC Unusual technical failure: Mind the patient height! ECA CCA balloon 5 cm to bifurcation Mo.MA system length: 95 cm Patient’s height: 181 cm If >170 cm Brachial approach or high radial artery puncture
  34. 34.  Patients: 76/267 (28.4%, 42 RA, 34 BA)  Crossover to FA: 1.3% (1/76)  Crossover to filter: 6.5% (5/76) - intolerance to occlusion: 4 pts - Mo.Ma too short: 1 pts  MACCE (PPA): 0% (0/71)  Major vascular complications: 1.3% (1/76) - brachial artery pseudoaneurysm  Chronic artery occlusion (31d-F/u): 7.1% - radial artery: 3/42 - brachial artery: 0/34 Transradial CAS with proximal protection Personal Experience September 23 2016 by Doppler US

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