Dimitriadis Dimokritos MD
interventional cardiologist
THESSALONIKI
Five steps for
success
A thorough knowledge of the basic angioplasty equipment is required for coronary intervention.
✓The correct choice of equipment can make a complex intervention appear effortless,
✓whereas the less appropriate equipment choices can make a straightforward intervention, laborious and challenging.
Can we have the right tool to do the job ?
First step: the puncture
•Trans femoral access
•Transradial access
•Left distal transradial access in
the anatomical snuffbox
55 years male with
nstemi!
Second step: the guiding catheter
✓Guiding catheters
✓Wires
✓Balloons
✓Stents
PCI material Selecting the right material for the procedure
Guide Catheters
The single most important choice (afterpatient selection) for the performance of a
successful intervention is the selection of the appropriate guide catheter (Safety, ease of the
case, case duration)
Role of Guiding Catheter
✓Atraumatic tip
✓Preformed curves and configurations
✓Torque control
✓Kink resistance
✓Radiopacity
✓Support
✓Device Compatility
Important Features of a Guide Catheter
✓Hub – “handle” configuration.
✓Shaft – polyurethane or polyethylene with wire/nylon braiding to provide
support and torque transmission. Catheter gradually softens from proximal to distal tip.
✓Tip – soft and atraumatic; of varying shape and length; radiopaque marker.
Components of a catheter
Diameter Side holes LengthCurve
style/length
Guide Catheter Selection
French size influence
7-8 Fr Guides6 Fr Guides
✓Increased support✓Improved visualization✓Better torque transmission
✓Larger puncture site✓Pressure damping✓Increased contrast usage
✓Small arterial puncture✓Brachial/radial access✓Less contrast✓Less back bleeding✓Deeper engagement
✓Decrease support✓Decreased visualization✓Decreased torque✓Smaller internal lumen✓Device limiting
PR
OS
CO
NS
Side holes allow perfusion but don't prevent guide catheter injury to the ostium
Guide catheter side holes
To improve antegrade perfusion when a large catheter engages a small coronary ostium, catheters with side holes are helpful.
They are also useful in PCI of a lesion located very proximally to or at the ostium
Types of Guiding Catheters Curves
Standard➢Standard guides provide coaxial alignment for the majority of patients with relatively straight forward aortas and vessel orientation. These guides often ride above the sinuses or rarely reach into the sinus
Support➢Support guide catheters derive their support primarily from the sinus of Valsalva
Extra Support and specialty Curves➢Gather their support from the opposite wall of the aorta
Types of Guiding Catheters Curves
Judkins left catheter showing the contact point (+) with aorta providing back-up support
Extra back-up curve catheter with large area of contact (+) between catheter and contralateral aortic wall, providing greater support
How to chose the right guiding catheter?
Why so many sizes and shapes?
The third step: guide wire
✓Guiding catheters
✓Wires
✓Balloons
✓Stents
PCI material Selecting the right material for the procedure
Wires
The choice of guide wire is second only to choice of guide catheter for
the performance of successful intervention
Common terms used to describe guide wire main characteristics
To steer through the vessel in order to access and cross the
lesion
To support and facilitate delivery of any interventional
devices
✓Steerability✓Torque ✓Flexibility ✓Visibilty✓Crossability✓Trackability
ROLE-IMPORTANT FEATURES OF GUIDE WIRE
✓Support
Core
Tip
Outer covering
Wire Coating
The core material will affect wire performance: Flexibility, support, steering and tracking
Guide wires: Central Core
Stainless Steel: Excellent support, transmission of push
and torque, Steerable
Nitinol (Nickel and Titanium): Excellent flexibility, kink resistance
High Tensile Strength Stainless Steel: Shape retention,
Excellent steering, tracking
A more practical classification of guide wires
Workhorse guide wires strike a nice balance between tip flexibility, shaft support and steerability
Secondary curve matches vessel size
Primary curve matches most angulated vessel bend
Forth step: the balloon
✓Guiding catheters
✓Wires
✓Balloons
✓Stents
PCI material Selecting the right material for the procedure
balloons
✓Dilating force
✓Pushability
✓Trackability
✓Crossability
✓Confromability
✓Inflation/deflation times
✓Withdrawal
✓Wire movement
Requirements of PTCA Balloons
Guidewire exits balloon catheter several cm proximal to the distal tip
Guidewire travels separately from the balloon catheter180 through 195 cm steerable is typically used
(+) Single operator
Allows for quick exchange of balloons
(-) Can’t reshape or exchange guidewire
without losing positionPushability may be compromised due tothe short wire lumen
Consists of a balloon catheter with a movable guide wire passing through the
entire length of its lumen 300 cm steerable guide wire is typically used
Rapid Exchange-Rx
(+) Ability to change guidewire without
losing positionSuperior pushability
(-) Typically needs 2 operators
Slightly larger profiles and shaftsCan take more time requiring more fluoroscopy
Over the wire-OTW
Longer taper reduce profiles and enhance crossability
Steep transition deliver focal dilatation and minimize edge dissections
Catheter Tip examples and Balloon Transition angles
Trackability refers to the balloon’s ability to track the wire up to the target lesion while
pushability refers to the ability to cross the lesion with the balloon. These are not easily
measured in vitro but are perhaps more important than catheter profile in today’s practice of interventional cardiology
Compliant: Diameter increases in
ratio with the increase in inflation force (size of balloon may grow beyond the ceiling of clinical safety)
Non-compliant: reach and
maintain specified size regardless of inflation pressure (little to no flexibility in vessel sizing)
Semi-compliant: Wide working
pressure with controlled flexibility in balloon sizing
Balloon Compliance
Dogboning
Do not re-wrap very well and, thus, can be difficult to re-use after initial inflations.
Circumferential Rupture
Balloon separates in two halves
Longitudinal (Axial) Tear
Balloon ruptures in a clean tear along the length of the balloon
Pinhole Puncture
High pressure jet of contrast forced through pinhole and directed at vessel wall
Balloon Burst Patterns
Fifth step: the stent
✓Guiding catheters
✓Wires
✓Balloons
✓Stents
PCI material Selecting the right material for the procedure
Stents
The Value of Thin Stent Struts
✓Reduced acute injury
✓Reduced inflammation
✓Rapid incorporation of struts
within neointima
✓Rapid re-endothelialization
Pre-Clinical Models have demonstrated
Stent Platform Evolution From Stainless Steel to Platinum Chromium
Future of Stents
• Thinner Struts
•Abluminal drug delivery
•Biodegradeable polymer
• Polymerless stents
•Biodegradeable stents
An important factor of uncertainty about the efficacy of drug-eluting stents is the use of polymers.
✓Time and rate of degradation
✓Suboptimal Scaffolding and radial force over time
✓Recoil early and late
✓Radiopacity of the stents
✓In vivo elution of drug
✓Complex implantation technique-difficult deliverability
✓Maintenance of stent integrity before, at and post deployment
✓Remaining polymer (inflamation, giant cells, fibrin, prothrombogenic effects)
✓Biodegradable products
THANK YOU!