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Coronary Interventions 2

LeftMain PCI : Basic techniques data from trials and ways to bail out complications
Dr. Ramesh Daggubati
Dr. Ramesh daggubati , Clinical professor ,  East Carolina Heart Institute, US,LeftMain PCI : Basic techniques data from trials and ways to bail out complications.
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Dr. Ramesh Daggubati

Clinical Professor

East Carolina Heart Institute, US

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Complete Transcript

Dr. Ramesh Daggubati > Do femoral state so that they will learn what is the normal state, what is high state and the low state. Recently, my fellow cut above the inguinal ligament in a very thin woman because he could feel the pulse very well over there, so I said he did not feel the inguinal ligament, so we have lost the art of actually teaching how to do femorals. So we are trying to go back to that and that patient will never have a cannula if need be from that site right. They may do not want a high stitch and put a 14-French guide catheter, I mean she can do transcatheter aortic valve replacement. So accordingly, we will talk about the theta angle very important and the deep seating guides are very important than IV left 3.5 is single guidewire that I used both for right and left and it saves time, because I do not have to exchange the guide catheter and that is why I use it, but again the number of co-axial and larger French site. (01

00) Larger French site is used definitely. If you use a #7-French guide, you will get a better support for delivering any device. At the same time, you may even cause thrombose remember of that. So lets us look at some complications and/or embolization. I told you that my patients actually had to go for surgery because the entire left main was shut down and I still do not know what happened and air could have been a cause. We could have injected air or we could have raised an atheroma or plaque or somehow thrombus may been at the sheath that we might could have dragged a catheter, I mean through the sheath so we could have drag the thrombus and injected into the left main and so dissections can happen and if any complications at any level where the guide catheter is going through can happen. At one time, I did a transcatheter aortic valve replacement, the balloon burst while doing it. We did not know what to do (02:00), and normally we pulled it out. It sheared the entire iliac artery and abdominal aorta and the patient had reopened up and unfortunately we cannot make it out. So these catheters are not harmless. They are harmful. If you look at this study from keenly, this aortic retrieved from tip more than 50% guide catheter and there is a large tip that is removed from JL and multipurpose catheters and where little amount from JR just because of the shape of the guide catheter. How many people in this room just by the raise of your hand shall remove the guide catheters over-a-wire every time? When I was trained, I never removed it over-the-wire. Just after finishing it, just pulled it out. I mean it did not make any sense to me why am I pulling like that and so I never was trained after finishing my fellowship, because I am not (03:00) in the attending thus we have to listen to what was attending wants. So but the way I do it is, I always remove the wire. Why? It is much better than scraping, even if it is soft and if the tip is soft I am not sure I do not like this. I just idea and it has not been proven, yes. If you remove the area without the wire you can cause more harm than good. So aspirate vigorously atheroma or thrombus is scooped up from the aorta can be injected into the artery, insists on bleed pack, I think how much we have to use it to prevent air embolus and avoid blood standing in the guide catheter especially if it is contrast even though you heparinize saline, but it can cause more damage and avoid Amplatz catheter for proximal ostial disease and care with that dimension to side walls and deep engagement (04:00) that is just pulling out. So I do not do that. Air embolus can cause acute ischemia after coronary injection, it can cause hypotensive and becoming bradycardic or abnormal sometimes V-Fib and sometimes it may transient. You may just give them 100% oxygen and they may be okay, but watch for the EKG changes and may be keep a close watch on that to defibrillate the patient and what are the appropriate conditions for that, a large diameter catheter, no bleed pack, and air visible in coronary. Everything this is mentioned here I can think about it I think about it, there is new thing came up cryo balloon so they somehow they wanted to shoot at the left atrial aortogram, angiogram and they injected air instead and somehow so that patient actually had died and so V-Fib had died. So nothing what we do is very simple (5:00) and without complications. So ischemia can happen in the capillaries, ischemia in gas bubble can be injected and that is why we have to be very careful and even people therefore sometimes have a stroke from these and so we can immediately see what happens to ischemic changes on the EKG and at one time, this is very common, people come back after catheterization. Sometimes they have contrast-induced nephropathy could be from it. They have otherwise some small skin changes you have to look at the feet most of the people might have some embolic phenomena into the leg and especially peripheral vascular disease patients. So catheter dissection I am not sure I do not want anybody to raise their hands, but there is something that all of us (06:00) probably will face at least once or twice in our lifetime. We try to avoid it, but always remember the first left main guide catheter induced dissection that I had the patient died. It is very, very bad. So do not waste time. You always have to think about what stent I am going to ask if there is a left main dissection. It does not matter right. You know you can post dilate to 5-0 now with most of the stents. So in your mind just think about what size stents do I ask. You know, keep at 3.5 and some number, random number, whatever you are comfortable with and do not surprise keep it very small and narrow, we have to choose the 3.5 or larger stent and longer stent and it is much better. So have that and ask for that and put that one in first and then think about taking pictures. Once you know, stop taking pictures (07:00) and put a stent in and then meanwhile tell the nurse and also call the surgeon and they will come into the room and evaluate the patient. You probably have saved the patient by being very quick and here there is very common that we see is left main dissection and sometimes these people are sent for bypass surgery and then the patient has a LIMA. The patient comes back. The LIMA is atretic because this guide catheter-induced dissection probably yields on its own. So can you watch, you can as long as the patient is not having chest pain, the patient does not have any ECG changes and probably can hemodynamically stable, you can watch or if all those things are there then you treat them with the stent. So, I think it was quickly grow over the coronary Guidewire. Guidewire are basically through once we get the guide in, we have to use a guide wire to deliver the stent (08:00) and you have to always take a atraumatic tip, adequate rail support and it has to appear smooth coating. Hydrophilic versus nonhydrophilic is different. I always tried to tell all the fellows who I worked with that nonhydrophilic wire such as a BMW wire. You want hydrophilic lubricity more and you can choose a whisper wire. You may not know where you are going so you want to learn about how your want to see, how it feels and nothing gives you a greater feel than actually the BMW wire and though you need to have that and take a different nonhydrophilic coating or silicon coating and they are also very lubricious and they can go down even smaller branches without making you have the feel for how they are and now a days the robotic PCI (09:00) is coming up and then you completely lose the feel with robotic PCI. Now that we want to prolapse and once after the lesion such as BMW as an atraumatic tip and shorter and you can actually prolapse and go down the vessel, but where as the longer tip, it is better wire tracking but it does not prolapse and that cannot be able to get you to point where you want and will show you that here there is longer tip where you have to go in that directions making to the side branch where as with shorter tip, it prolapses and you have to have an art to actually be able to deliver into the side branch and you can successfully get into any branch with a lot of experience and guidance. So stainless steel is the original ones that we use but now most of them are actually become several Nitinol wires (10:00) and four wires on the distal end to increase the flexibility where there are springs and coils and if you actually cause damage to the wire that it can uncoil and become multiple wires and though that is not a good thing either and you do not want to do that. So if it is Nitinol can retain the shape when you bend it, it still retains it and you do not have to damage and to keep resistant and excellent steering and flexibility is present in Nitinol wire. So the work of the Guidewire has to set the intermediate core diameter is not too thin, too small or too wide and gentle core taper, soft tip and smooth coating is there on the wire. So it is also remembered that atraumatic tip is very important. You have to be able to thought transfer (11:00) again one time you done it and then making 90 degrees, it should turn exactly the same amount and most of us now we see we just feel that the wire particularly soft is transfer is actually assessed by putting a tosser on the end and trying to feel how much it can rotate and good tactile steel steering and pushability and none of the FFR wires are at this range right now the companies working to make the FFR wires as ideal FFR wire as possible in the current. I think everybody agrees that probably BMW is the most ideal and it is goes with the ideal that we can get and usually you have to have the support to be able to get the stent. If not, you have to use extra support. For CTOs the specialty wire such as Fielder Miracle (12:00) Brothers and Confianza all of these wires when you call for these wires, think about couple of things. Do you have a covered stent in your lab, so those are the things that you have to think about, the dual stents and cover stents, because you can call for operations and dissection and hydrophilic whisper wire and a ChoICE PT is very good and very nice. They are going to branches that you will not expect them to go and to learn that and they have to out number them. So in lot of parts lot of people use BMW and Pro What has also run through and the agent of the different companies make their own work of wires, high soft, floppy, so whatever you are used to just try to do one or two workhorse wires and go to BMW my colleagues did run through. I think what are the causes that complications that you can have (13:00) if the tip is not soft. If the tip-tip dissections were present, very increased rate supporting can straighten an artifact and you think sent unnecessarily thinking all the supervisions of lesions are stented and hydrophilic coating can lead to perforations. So here this is the lesion that you wanted to and once you put a wire, then you see this lesion Oh my god now what did I do I caused some damage with the wire so you can go ahead and put a stent from here to here all the way, right, which is not the right thing actually you may balloon it and pull back the wire to the softer tip area and then reassess the area that there is not a lesion actually. So before the Sandeep comes, balloon angioplasty, Harika what is the use of balloon angioplasty, to predilate to facilitate stent. Now-a-days I think still ideally (14:00) you should not stent if there is an excellent balloon results, but not sure how many people just do go by alone. We call it poor old balloon angioplasty, I am not sure, but ideally if there is a successful balloon angioplasty it is noticed that it can reduce to 30% from whatever 90% and so 30% we can leave it alone and we do not do that. So we do balloon angioplasty just as it facilitates stent deployment over artery. Over the wire balloon catheters and monorails. Monorails are taken over because we can just do it single-handed for two people, but definitely two or more people are needed for whole the wire balloon. I use monorail for 99.99% in order if it is CTO, I do not use whole wire balloon. So balloons similar packability, (15:00) pushability, promoting profile is very important in a smaller shaft of the balloon profitability profile is great, but that means it can actually tear, it can break, we have to have still the pushability should not be compromised, but profitability and ao how does it inflate complying and dilating both nominal pressures rated with pressure all these you have to you, but just remember if you go on any balloon, any quality of state. So let look at compliance, compliance depends upon actually the material that whether it is polyethylene, nylon or polyolefin. So polyolefin is compliant and polyethylene and nylon are semi-compliant and noncompliant with that thin polyethylene (16:00) phthalate or something like that So those above non allowed compliant balloons can increase in size whereas the noncompliant balloons do not increase in size. So do not think that I put a 3-0 stent and I am going to post-dilate with 3-0 balloon. You are not going to make it into 3.5. It is going to 3.0 or 3.05 at the most. It is not going to become 3.5. So always if you are doing 1:1 stent and if you want to override this they will go up to 3.05 or 3.5 balloon, but remember this trap noncompliant is actually it does not increase in diameter. So different balloons are given here by different companies and some of them can grow as little bit more if the slit is noncompliant, now it is noncompliant, if you are compliant, and it does not go much from 3 it goes up to 3.1 at 18 atmospheres. (17:00) So there is no need to do higher inflation with noncompliant balloon. All you are trying to do is probably you are going cause H dissection now. If you want to really post dilate, take a 3.25 balloon or 3.5 balloon and go to nominal pressure and then you will not cause actually more H dissection in case of the balloon stops coming out of the stent. So this is how it looks semi-compliant and noncompliant is actually low on focal growth as pressure increases and designed for dilatation of calcified lesion. Even for aortic balloon angioplasty is now called a true balloon, which is definitely much more noncompliant. It can even tear the aorta if we want and be careful how good noncompliant is. We have to choose the right one (18:00). So better flexibility and packability of compliant balloon which we will lose all these with noncompliant balloon. So noncompliant actually makes it more difficult to cross the lesions. We will lose the pushability and so we have to probably predilate first and after you put a stent. We have to probably post dilate this noncompliant but if you straight away go with a noncompliant you may not be able to successfully dilate the lesion, but you so might go step wise with increasing the balloon sizes. So I think in view of time we talk about. So when you want to go to high pressure it is almost always very rare or never. Do not try to go higher pressures more than 80 and especially I think now we are going a higher pressure with DBS again and so if this is the device delivery problems and we talked (19:00) about getting buddy wires, guidelines, more flexible stent which we will listen from Dr. Mishra and stiffer guidewire which is important.

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