THE PARALLEL SHEATH TECHNIQUE IN SEVERE
ILIAC TORTUOSITY
DR. JUAN CARLOS BECERRA MARTÍNEZ
SERVICIO DE HEMODINÁMICA
UMAE HE CMNO
GUADALAJARA, MÉXICO
Eurointervention 2014;10:231-235
Nicolaus Reifart: Director of the Main Taunus Heart Institute in Bad
Soden, Germany.
Chief of the Departments of Cardiology at the Red Cross Hospital and Heart Center in Frankfurt until 1997
Eurointervention 2014;10:231-235
Introduction
In some elderly patients catheter manipulation via the femoral approach:Is barred by a high level of friction due to
severe kinking of the iliac artery (atherosclerotic vessel remodelling)
Eurointervention 2014;10:231-235
Introduction
Common solution:To use a larger, rigid, kink-resistant long
sheath with a stiff guidewire.Nevertheless, in rare cases the kinking
cannot be overcome ○ Puncture the contralateral side○ Switch to the transradial approach
But… the atherosclerotic disease is often generalized might also be extremely difficult
Eurointervention 2014;10:231-235
Indications for Use Severe tortuosity of the access arteries that
prevent acceptable manoeuvrability of catheters
It will dramatically reduce friction
We do not recommend using closing devices after the end of the procedure.
Eurointervention 2014;10:231-235
Tips & Tricks
Keep a catheter and a stiff 0.035” wire in the first sheath
Puncture 1-2 mm medially (sometimes
laterally) aiming towards the palpable sheath
It appears appropriate to use a 4 Fr sheath
Eurointervention 2014;10:231-235
Five Cases
The common bail-out technique for all cases was parallel sheath technique
Two extra-stiff 0.035” wires
Eurointervention 2014;10:231-235
Case 1 79-year-old male
80% stenosis of the right common carotid artery
The 5 Fr dx catheter (right groin) didn’t advance although we used a long kink-resistant 8Fr 45cm sheath and a 0.035’’ extra-stiff guidewire
Eurointervention 2014;10:231-235
Case 1 Switch to left groin Failed too
Right side again: Second long 5 Fr 45 cm sheath parallel to the 8 Fr sheath
Advanced a stiff 0.035’’ guidewire via the 5Fr sheath, nicely straightening the artery.
The common carotid artery was then successfully dilated and stented.
Eurointervention 2014;10:231-235
© 2
014
Eur
oInt
erve
ntio
n. A
ll rig
hts
rese
rved
.
EuroIntervention 2014;10:231-235The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve catheter manoeuvrability
Case 2
73-year-old male
3-vessel coronary artery disease & CABG 17 years ago. Angina pectoris CCS IV
In spite of severe iliac kinking:
Dx angiography with 5 Fr catheters was achieved using the right groin, a kink-resistant long 5Fr sheath and a 0.035’’ extra-stiff guidewire
Eurointervention 2014;10:231-235
Case 2
Dx angiography :50% stenosis of the LM80% lesion of the proximal LADOcclusions of the RCA and LCXBypass grafts to RCA, CX and LAD were
occluded.
Planned approach:PCI of LAD
Eurointervention 2014;10:231-235
Case 2 The 5 Fr sheath was exchanged for a 7Fr
45cm kink-resistant sheath (Figure 2A), but the guiding catheter could not be advanced
We inserted a second 5 Fr 45cm sheath parallel to the 7 Fr sheath
The vessel was straightened (Figure 2B) and we completed the via the 7 Fr sheath
Eurointervention 2014;10:231-235
© 2
014
Eur
oInt
erve
ntio
n. A
ll rig
hts
rese
rved
.
EuroIntervention 2014;10:231-235The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve catheter manoeuvrability
Case 3 71-year-old male with hip dysplasia (pre-operative)
EKG and ECO suggested ischemia.
Coronary angiography was impossible because of serious elongation and kinking of the iliac artery (Figure 3A), with the 5Fr 45cm sheath
We inserted a second long 5Fr 45cm sheath (Figure 3B)
Two-vessel disease with no indication for PCI.
Eurointervention 2014;10:231-235
© 2
014
Eur
oInt
erve
ntio
n. A
ll rig
hts
rese
rved
.
EuroIntervention 2014;10:231-235The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve catheter manoeuvrability
Case 4 75-year-old male
3-vessel disease & CABG 14 years ago
Dyspnoea NYHA Class II.
Due to massive whorls of the artery and severe friction it was impossible to manoeuvre the catheter (Figure 4A).
Eurointervention 2014;10:231-235
Case 4
Angiography was performed easily only after parallel insertion of two 45cm kink-resistant Arrow sheaths (5 Fr and 6 Fr) (Figure 4B)
Prognostically relevant progression of the coronary artery disease was ruled out.
Eurointervention 2014;10:231-235
© 2
014
Eur
oInt
erve
ntio
n. A
ll rig
hts
rese
rved
.
EuroIntervention 2014;10:231-235The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve catheter manoeuvrability
Case 5 74-year-old male
Symptomatic obstruction of the right superficial femoral artery.
A crossover manoeuvre via the left groin was impossible because of severe kinking of the ipsilateral iliac artery in spite of a kink-resistant 7Fr sheath and extra-stiff 0.035’’ guidewire
Eurointervention 2014;10:231-235
Case 5
Only after inserting a second 4 Fr sheath with a second stiff 0.035’’ guidewire (Back-up Meier; Boston Scientific) stenting of the SFA successful.
Eurointervention 2014;10:231-235
© 2
014
Eur
oInt
erve
ntio
n. A
ll rig
hts
rese
rved
.
EuroIntervention 2014;10:231-235The parallel sheath technique in severe iliac tortuosity: a simple and novel technique to improve catheter manoeuvrability
Conclusions In all cases the sheaths were removed
immediately and the groin compressed manually, without any bleeding complications.
In the presence of severe tortuosity of the femoral or iliac arteries, the insertion of a second arterial sheath parallel to the first with an extra-stiff wire will considerably ease manipulation via the first sheath.
Eurointervention 2014;10:231-235
Discussion This is the first report of a simple and novel parallel
sheath technique to improve steerability markedly in situations of insuperable femoral or iliac kinking.
Other possible solutions: Alternative access Bigger sheath size Small sheath into a big sheath Dental floss technique
○ Not suitable for coronary interventions
Eurointervention 2014;10:231-235
Do not reduce friction
Discussion
The parallel sheath technique has been applied by Dr. Reifart since 2006 in more than 500 cases of CTO (7 Fr and 5 Fr or 6 Fr) for contralateral injection or retrograde recanalisation approach.
Major in-hospital bleeding: <1%
Eurointervention 2014;10:231-235