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PTA OVERVIEW AND HARDWARE

PTA OVERVIEW AND HARDWARE. DEEPAK NANDAN. INTRODUCTION. Endovascular revascularization of infrarenal aortic and iliac disease- high rate of technical success and with lower morbidity and mortality than open bypass surgery

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PTA OVERVIEW AND HARDWARE

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  1. PTA OVERVIEW AND HARDWARE DEEPAK NANDAN

  2. INTRODUCTION • Endovascular revascularization of infrarenalaortic and iliac disease- high rate of technical success and with lower morbidity and mortality than open bypass surgery • Preferred modality for treatment of patients with Trans-Atlantic Inter-Society Consensus Document (TASC) II type A and B lesions • Surgical revascularization preferred for patients with TASC type C and D lesions • In contemporary practice, surgery is reserved for failure of endovascular approach

  3. Modified TASC Morphological Classification (TransAtlanticInter-Society Consensus)

  4. TASC -Femoral-Popliteal Lesions

  5. AortoIliac and Common Femoral Intervention

  6. 5 YEAR PATENCY RATES OF AORTOILIAC INTERVENTIONS

  7. Vessel diameter

  8. Recommendation for vascular access of aortoiliac intervention

  9. Vascular Access • Relatively disease-free, without signi Ca • Over a bony structure, if possible • Angle of entry- 30⁰-45⁰ • Obtained with an 18-gauge needle that will accommodate most 0.038 “ or smaller Wires • A smaller 21-gauge needle with a 0.018-inch wire - “micropuncture kit” (Cook, Bloomington, IN) • Used for difficult femoral, brachial, radial, or antegrade femoral approaches

  10. Retrograde Common Femoral Artery Access Contralateral femoral retrograde access iliac occlusions are best treated from a contralateral approach SFA,PFA- lesions OF CFA/involve SFA/PFA ostium - allows treatment B/L disease with a single arterial puncture • Common access site used for peripheral diagnostic angiography and intervention • Prevent injury to the less diseased extremity

  11. Femoropopliteal Artery Intervention • Contralateral femoral retrograde access : Manual ofcarotidandperipheralvascular Intervention, ThosapholLimpijankit MD, Beyond Enterprise Thailand 2008;290

  12. Antegrade Common Femoral Artery Access Ipsilateral popliteal retrograde access Useful in SFA occlusion with failure to cross from contralateral or antegrade Ostial SFA/CFA lesions may also be approached via PA in acute angled terminal aobifurc CI- aneurysms of PA, pathology of poplitealfossa- Baker’s cyst • Required for infrainguinal proced • Approx 3cm CFA lies betw ligament & FA bifurcation • Inorder to access CFA, skin entry- prox to ing ligm • Access too close to F bifurc –inadeq working room to selectively cath SFA

  13. Brachial Artery Access • Pref access for visc arterial [CA, SMA] interventions • PC approach at BA can lead to a ↑compli rate • UL arts – smaller, prone to spasm • A small hematoma- Could lead to brachial plexopathy • Itvreq >6F sheaths/smaller pt→open approach preferred • Left BA access pref over Rt- can avoid carotid origin • A micropuncture tech should be used for all PC BA intervention • Left brachial approach has approximately 100 mm greater reach than the right brachial approach

  14. Estimated distances from FA access

  15. GUIDEWIRES

  16. Guidewires are used to introduce, position, and exchange catheters • In a standard guide wire, a stainless steel coil surrounds a tapered inner core • A central safety wire filament is incorporated to prevent separation in case of fracture • 5 charecterstics- size, length, stiffness, coating, and tip configuration • Typically they are 100 to 120 cm in length but can also be 260 to 300 cm (good rule of thumb to follow is that the guidewire should be twice the length of the longest catheter being used) • Tip of the wires can be straight, angled, or J-shaped • Varying degrees of shaft stiffness- extra support,to provide a strong rail to advance catheters in tortuous anatomy vs extremely slick hydrophilic with low friction

  17. Wire selection • Diameter vary from 0.014“ to 0.038“ • Most commonly used size is 0.018“/0.035“ ( upper extremity) and 0.014“/ 0.018“ ( lower extremity) • Length between 130 and 300cm • Tip configurations are; straight, angled Tip and J shape • Varying degrees of shaft stiffness ( e.g. extra support, super stiff wires) allow advancement of stiff devices • Hydr-angle tip–Glidewire • Can be used for crossing tight lesions and can be advanced independent of a guidewire • 038:18g needle, 018:21g needle

  18. Guidewire-Lesion Interaction • Floppy portion moving in a linear fashion • Floppy portion piles up prox to lesion—no chance to cross- backup,redirect,if straight tip→steerable • Floppy tip bent with min R—Cautiously adv wire- once crossed, wire should straighten- advancing a “buckledup” wire- force→embolization • Floppy tip “buckledup” —backup,redirect,adv -dissect,embolz,wiredamag

  19. PTA Guide wires Guide wire Functions PTA Guidewires are designed to: • Track through the vessel • Access a lesion • Cross a lesion • Provide device delivery support

  20. Coils & covers Outer coils Tip coils only Polymer cover Polymer sleeve Tip coils

  21. Coils & covers • Coils provide tactile feedback, radiopacity and maintain constant overall diameters • Polymer covers/sleeves provide optimal lubricity to overcome resistance and access to the lesion Allows smooth tracking through tortuous anatomy Better device tracking over the guidewire Not to be confused with coating (hydrophilic or hydrophobic)

  22. Covers and Coatings – Summary Tactile Feedback (relatedtocoils) Lubricity Polymer Cover with hydrophilic Coating Hydrophilic Coating Hydrophobic Coating No Coating Delivery &Device Interaction

  23. PTA GUIDE WIRES • Terumo Glide Technology™ hydrophilic coating • smooth, rapid movement through tortuous vessels crossability over difficult lesions • Core-to-tip design provides 1:1 torque ratio • elastic nitinol core for optimal performance • Resists kink &Retains shape • Tungsten in polyurethane jacket- radiopacity • Carries the risks of vessel dissection • and perforation • should not be used to traverse needles because of the potential of shearing • Glidewire (TERUMO) Peripheral Guidewires(0.032"-0.038") Standard Glidewire Shapeable Tip Glidewire Long Taper Glidewire Stiff Shaft Glidewire Stiff Shaft Long Taper Glidewire 1 cm Taper Glidewire J-Tip Glidewire Bolia Curve Glidewire Glidewire Advantage™ Small Vessel Guidewires(0.018"-0.025") Glidewire Standard and Shapeable T ip Glidewire GT Super-Selective Glidewire Gold

  24. ABBOT Hi-Torque Steelcore Peripheral Guide Wire (190/300 cm) Hi-Torque Spartacore Peri Wire • Excellent .014" Support SS shaft • Superb Steerability and a Soft Shapeable Tip • Core-to-tip design • 130/190/300 cm lengths • MICROGLIDE Coating • PTFE up to distal 7 cm (130 cm) • Available in 5 and 10 cm

  25. Hi-Torque Supra Core 35 • One-to-one torque • exceptionalsteerability • MICROGLIDE coating • Radiopaque tip • 035" shaft • Soft Shapeable tip Hi-Torque Versacore Guide Wire • Torqueable wire for deliverability through tortuous or challenging lesions • Soft shapeable tip designed to for lesion acces

  26. BOSTON SCIENTIFIC

  27. Amplatz Super Stiff Guide Wire • For stiffness, strength and stability during catheter placement and exchange • Diameters: 0.035", 0.038" • Lengths: 145cm,180cm, 260cm • Tips Styles: Straight, J, Short • Core Material: Stainless steel • Coating: PTFE Magic Torque Guide Wire • Magic Markers spaced at 1cm increments • designed for enhanced visualization and excellent torque control • Diameters: 0.035" • Lengths:180cm, 260cm • Tips Styles: Straight (shapeable) • Core Material: Stainless steel • Coating: Glidex Hydrophilic Coating (tip)

  28. Meier Guide Wire • Stiff shaft excellent supp • flexible tip is ( AAA endovascular graft procedures) • Diameters: 0.035" • Lengths: 185cm, 260cm, 300cm • Tips Styles: J, C • Core Material: Stainless steel • Coating: PTFE Platinum Plus Guide Wire • Designed for negotiation of tortuous anatomy and contralateral approaches • Diameters: 0.014", 0.018", 0.025" • Lengths (cm): 60, 145, 180, 260, 300 • Tips Styles: Straight – Long or short taper • Core Material: Stainless steel • Coating: Glidex Hydrophilic

  29. Thru way Guide Wire • Designed for excellent performance in acutely angled vessels, such as renals and other peripheral interventionsDiameters: 0.014", 0.018" • Lengths (cm): 130, 190, 300 • Tips Styles: Straight, J • Core Material: Stainless steel • Coating: Silicone

  30. CORDIS • EMERALD™ Guidewires • Fixed-Core, PT F E Coated, Exchange Wires

  31. COOK Amplatz Stiff Wire Guides • Stiff shaft • Gradual transition to a very flexible distal tip • TFE Coated Stainless Steel-035,038: 145,180,260-straight • TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260-straight • 8 cm-flexi tip Amplatz Extra-Stiff Wire Guides • ↑ inner diameter -extra-stiff + tip flexibile • TFE Coated Stainless Steel-025,035,038: 80,145,180,260-straight & curved: • 300-straight • TFE Coated Stainless Steel with Heparin Coating-035: 80,145,180,260-straight & curved

  32. Amplatz Ultra-Stiff Wire Guides • The increased inner diameter of the wire guide coil allows utilization of an ultra-stiff mandril while maintaining tip flexibility • TFE Coated Stainless Steel-035,038: 80,145,180-straight • TFE Coated Stainless Steel with Heparin Coating-035: 145,180-straight • 8cm-flexi tip

  33. Roadrunner Extra-Support Wire • Complex diagnostic/interventions - where extra support needed for cath exchange /manipulation of devices • Heavy-duty nitinol alloy mandrilprovides support while imparting 1:1 torque response to distal platinum spring coil tip • Angled tip facilitates directional control • Lubricious TFE coating -low coefficient of friction • 014,018 • 180,270,300

  34. Cope Mandril Wire Guides I • Stainless Steel • Platinum coil ↑visualization and an angled floppy tip for precise directional control • 018 • 40,60,100,125 • Standard taper-7cm coil CopeMandrilWire Guides II • Nitinol kink resistant 1:1 torque control • Platinum coil -↑visualization • angled floppy tip for precise directional control • 018 • 60,100,125 • Standard taper-7cm coil, short taper-7cm coil

  35. Rosen Curved Wire Guides • The heavy-duty mandril, 2 cm flexible tip and tightened “J” configuration • Ideal for Renal int- less traumatic • TFE Coated Stainless Steel-035: 80,145,180,220,260 • TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260

  36. The Graduate Measuring Wire Guides • Used to determine accurate sizing of vessel • Gold radiopaque markers delineate 25 cm length • Six distal markers are spaced 1 cm apart. • Four proximal markers are spaced at 5 cm increments. • 035 • 145,180

  37. Reuter Tip Deflecting Wire Guide • Used with Reuter Tip Deflecting Handle for curving or deflecting catheter tips during selective and superselectiveangiography • Facilitates catheter tip movement by controlling the deflection of the wire guide tip within catheter lumen • Distal tip of wire guide must never extend beyond tip

  38. BIOTRONIK Cruiser Guide Wire • 0.014“ • L: 190 cm • Tip Shape: Straight and J Cruiser-18 • Hi-support Guide Wire • 0.018” • Stiff: 195 cm and 300 cmMedium: 195 cm and 300 cm

  39. Catheter An “ideal catheter” should be able to sustain high-pressure injections, to track well, be nonthrombogenic, have good memory, and should torque well

  40. Catheter ( diagnostic/ guiding) Length depends on location for using Sizes are 5 to 8 French a) abdominal aorta = 60 to 80 cm length b) BTK,carotid or subclavian areas 100 to 125cm length Polyethylene- ↓coef friction, pliable Polyurethane- softer, even ↑pliable→ tracks wires better Nylon- stiffer, can tolerate ↑flow rate- amenable to angio Teflon- stiffest- used mainly for dilators & sheaths wire braid in the wall to impart torquibility and strength

  41. Guiding Catheter vs Sheath • Operator dept • Sheaths are designed with a simple diaphragm or a hemostatic valve, guiding catheters always require hemostatic valves be attached • During intervention, the guide catheter or sheath should be placed near the lesion to provide for better visualizationand improved support Flush /Non-Sel Selective CATHETERS

  42. BALKIN Sheath (cook) • Contralateral access to the iliac artery • Flexibility without kinking or compression • Radiopaque band- identifies precise location of sheath’s distal tip for positioning accuracy • The Check-Flo valve prevents blood reflux and air aspiration during catheter manipulations • 5.5 Fr-8 Fr- 40cm - .038” compatible

  43. Super Arrow-Flex® Sheath /Dilator Setwith 90° curved tip (ARROW International) • 6-7Fr • 45cm length Assures successful access to the renal arteries. “Y” Connector + TuohyHemostasis Valve a+ 3-Way Stopcock • 90° Curved Tip Both sheath and dilator have a curved tip for easy access to the renal artery • Sheath replaces guide catheter -eliminates the need for using a guiding catheter - reducing size of puncture • Radiopaque tip marker-locate and control sheath advancement into RA

  44. TERUMO GUIDING SHEATH(Pinnacle Destination) • Guiding Sheaths (5-8 Fr) • 5-8 F • 45,65,90 • Hydrophilic coating • All dilators are 0.038" wire compatible

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