Optimal equipment for radial access · 1. Kiemeneij F. et al. Hydrophilic Coating Aids Radial...

Optimal equipment for radial access (sheath selection, sheath length, hydrophilic coating, needle type)

Jacek Legutko, M.D., Ph.D. Professor of the Jagiellonian University, University Hospital in Krakow, Poland

President of the Association of Cardiovascular Interventions

of the Polish Cardiac Society

Speaker’s name: Jacek Legutko

I have the following potential conflicts of interest to report:

Research contracts Consulting: Volcano, St. Jude, Terumo

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

Potential conflicts of interest

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Mechanisms and Predictors of Failed Transradial Approach for PCI

Dehghani P, et al. JACC Cardiovasc Interv. 2009;2:1059-1064

Radial artery puncture – Right vs. Left

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Right or left RA ??? Radial artery puncture – Right vs. Left

Right RA… Left RA...

Operator’s comfort Operator has to bend

Lower radiation dose for physician Higher dose of radiation

Look out for RSA tortuosity LSA not so tortuous

1-catheter coronary angio Coronary angio with 2 diagnostic

catheters

Mind the size of the catheters (0.5 F

smaller than for transfemoral

Same size of catheters as for

transfemoral approach

Requires more catheter navigation for

coronary ostia engagement

Easier to engage coronary ostia

Angiography of LIMA might be tricky Easy accessible LIMA

Radial Artery Puncture – Right vs. Left

Left RA become green:

Very obese patient

Tortuous or occluded RSA

SVGs implanted

Difficult RCA intervention

Local anaesthesia Examine the puls

Skin incision RA puncture

Wire insertion Arterial sheath insertion

Puncture technique

Risk factors for …

… RA spasm … RA patency

Younger age Apropriate diagnostic.guiding

catheter size

Female

NTG/ligno/werapamil ia

DM

sedation

Small RA diameter 180-250 cm exchange wire

Multiple punctures Hydrophilic catheters

Lack of operator’s experience Delicate manovers with catheters

Warm saline injection ia/warm

covering on forearm

Workhorse in my cathlab – BALTON portfolio

Transradial Access Portfolio Radial Introducer Sheats

+ Regular J-Tip 0.035” Diagnostic Guidewires

Loops/turtuosity

Difficulties…

How to overcome the problem?…

Coronary guidewire (BMW, BHW, Extra Support wire)

Right Judkins diagnostic 5 or 6F catheter

spasm

Difficulties…

cocktail i. a. (Werapamil/NTG/ligno)

Long hydrophilic sheath

Sheathless catheter

If 0.035” diagnostic guidewire

doesn’t go

Use 0.014’ coronary guidewire to

introduce long hydrophilic sheath or

sheathless catheter into the brachial

or subclavian artery

Liang, et al. Catheter cardiovasc Interv. 2010;75:222-224.

Transradial Guiding Catheter Size Selection

http://www.asahi-intecc.com/medical/international/product/gc_se.php

Transradial Guiding Catheter Size Selection

Distribution of radial artery diameter

Saito S. Catheter Cardiovasc Interv. 1999;46:173-178.

Size of guiding catheters 5F 6.5 F

sheathless 6F 7.5 F

sheathless

External diameter

1.73 mm 2.16 mm 2.69 mm

2.49 mm

Kissing balloons

Not possible ok ok ok

Transradial Guiding Catheter Size Selection

Jolly S, et al. Lancet 2011;377:1409–20.

Perforations / hematomas…

In case of perforation the best prevention of large hematoma is exchange of your

sheath into appropriately sized Sheatheless guiding catheter and to continue the

procedure!!!

Pseudoaneurysms…

Usually they heal spontaneously, but sometimes surgery is needed…

Broad Range of Options

Transradial Kit

Special transradial

tapered introducer kit

M Coat

Hydrophilic M Coating

M CoatTM A-kit

M CoatTM R-kit

Thin-wall technology for 1

Fr reduction in outer

diameter

Hydrophilic M Coating

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

Transradial Access Portfolio Radial Introducer Sheats

Radifocus® Introducer II

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Suture eye Aids in securing the sheath to the skin

Colour-coded sheath support For size determination

Unique Terumo Cross-Cut Valve Avoids bleeding and air aspiration

Snap-on/Click-off dilator Prevents backout during insertion

Kink-resistant design Helps keeping the lumen open throughout the procedure

Radifocus Introducer II – M Coat:

M Coat Hydrophilic Coating Easy insertion and removal

Smooth guidewire-to-dilator and

dilator-to-sheath transitions Reducing penetration resistance

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

Radifocus® Introducer II

23

Suture eye Aids in securing the sheath to the skin

Colour-coded sheath support For size determination

Unique Terumo Cross-Cut Valve Avoids bleeding and air aspiration

Snap-on/Click-off dilator Prevents backout during insertion

Kink-resistant design Helps keeping the lumen open throughout the procedure

Radifocus Introducer II – M Coat:

M Coat Hydrophilic Coating Easy insertion and removal

Smooth guidewire-to-dilator

and dilator-to-sheath

transitions Reducing penetration resistance

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

• Unique thin-wall technology

• 1 Fr size reduction in outer diameter

• Maintaining larger inner-diameter equivalent

• M CoatTM hydrophilic coating

• Ease of insertion and removal

• Less penetration resistance than conventional sheaths1

• TIF Tip Technology

• Total Integrated Fit, optimal tapering design

for smooth penetration

Glidesheath Slender®

1. Kiemeneij F. et al. Hydrophilic Coating Aids Radial Sheath Withdrawal and Reduces Patient Discomfort Following Transradial Coronary Intervention: A Randomized Double-Blind Comparison of Coated

and Uncoated Sheaths. Catheterization and Cardiovascular Interventions 59:161–164 (2003)

Equivalent

Diameter 6 Fr 6 Fr

Sheath 5 Fr

Sheath

Equivalent

Lumen

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

7-in-6

6-in-5

5-in-4

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

Glidesheath Slender®

6Fr

7Fr

5Fr

7Fr GSS

5Fr GSS

6Fr GSS Down

Sizing

0.20mm 0.12mm

Glidesheath Slender Radifocus Introducer II

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

2.06 2.09 2.09

2.13

2.29

2.41 2.48

2.52 2.46

2.62

2.73 2.74

2.88

2.79

2.97 3.02

3.08

1.7

1.9

2.1

2.3

2.5

2.7

2.9

3.1

3.3

Cook FlexorCheck Flo 4F

CordisRadialSource

4F

Merit MedicalPrelude Radial

4F

TerumoGlidesheathSlender 5F

TerumoRadifocus

Introducer II5F

Cook FlexorCheck Flo 5F

CordisRadialSource

5F

Merit MedicalPrelude Radial

5F

TerumoGlidesheathSlender 6F

TerumoRadifocus

Introducer II6F

Cook FlexorCheck Flo 6F

CordisRadialSource

6F

Merit MedicalPrelude Radial

6F

TerumoGlidesheathSlender 7F

TerumoRadifocus

Introducer II7F

CordisRadialSource

7F

Cook FlexorCheck Flo 7F

The smallest 5, 6 and 7Fr sheath on the market

O.D. in mm

Above measurements taken from internal evaluation of competitive devices. Engineering Data on File. 4Fr 5Fr 6Fr 7Fr

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

Procedural success rate 99,1%

Low rate of radial artery

occlusion (0,88%)

Low rates of vascular

complications and spasm

Less invasive shorter

compression time

Routine use of

Glidesheath Slender (6F)

for angiography &

intervention is safe &

feasible

Potential to allow complex

PCI while limiting local

trauma to the artery

• 114 patients

• All comer population,

including ACS and

complex PCI

Aminian A. et al. Catheter Cardiovasc Interv. 2014;1;84:436-42.

1

Transradial Access Portfolio Radial Introducer Sheats

For more complex procedures, difficult access,

complications: TERUMO dedicated devices

• Atraumatic wire shape

– J-tip minimizes the chance of vascular damage

– J-tip avoids unintentional engagement of vascular

side branches

• Flexible wire morphology

– Tracks tortuous anatomy with ease

• Hydrophilic coating

– Minimizes the chance of vasospasm

Radifocus® Guidewire M J-Tip 0.035” Diagnostic Guidewires

One-piece

construction

Great steerability

Nitinol alloy core

Kink-resistant, for faster

navigation through even

the most tortuous vessels

Transradial Access Portfolio Guidewire

1.5 mm J-Tip guidewire,

tracking through the radial

artery with an average

diameter of 2.3mm1

Transradial Guiding Catheter Size Selection

Transradial Guiding Catheter Size Selection

Transradial Guiding Catheter Size Selection

Pulsoxymetry monitoring during the

procedure

How to reduce the risk of RA occlusion?

European Heart Journal (2012) 33, 2521–2528

Proved May decrease the risk Not really reducing

the risk

Anticoagulation

(UFH, 5000 U, even for

coronary angio)

Hydrophilic sheath Long vs short sheath

Patent hemostasis RA spasm prophylaxis Sheathless technique

5F > 6F > 6F > 7F Shorter compression

after procedure

Avoid puncturing the

same RA again

Conclusions

Routine

procedure

RA Spasm

HC

RA perforation

Need for large

lumen GC

Thank you for your attention!

2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College

2nd Department of Cardiology and Cardiovascular Interventions, University Hospital in Krakow Poland