The First Affiliated Hospital of Harbin Medical University How to improve stent Deliverbility ? Li Yue, M.D. The First Affiliated Hospital of Harbin Medical University

Challenges for stent delivery Severe calcification Proximal vessel tortuosity Sharply angulated segments Diffuse disease Angiography was performed Through the radial approach using a tiger catheter.

Tips and tricks for stent delivery Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS) Angiography was performed Through the radial approach using a tiger catheter.

Inner catheter 5 in 6 guiding catheter technique Heartrail II (Terumo, Japan) long (120 cm) 5 Fr catheter Absence of curve and the flexibility of its tip permit the “child” catheter coaxial with the target vessel, minimizing the risk of dissection. Angiography was performed Through the radial approach using a tiger catheter.

Coronary artery injury Angiography was performed Through the radial approach using a tiger catheter. Coronary artery injury Deep-vessel engagement can be facilitated by passage of a balloon catheter Air embolism

Angiography was performed Through the radial approach using a tiger catheter. 7F AL-1; 3.5mm balloon

Angiography was performed Through the radial approach using a tiger catheter.

(Goodman, Japan) Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter. The lumen size of the aspiration catheter as the size of SES is limited to 3.0 mm.

GuideLiner cath Rapid exchange Flexible yellow 20 cm straight extension connected to a stainless-steel push tube Results in an I.D. approximately 1F size smaller available in three sizes: 6F, 7F and 8F Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Not recommend its use in target vessels of < 2.5 mm diameter Angiography was performed Through the radial approach using a tiger catheter. Not recommend its use in target vessels of < 2.5 mm diameter

Softer tip and hydrophilic coating on inside and outside. 5-Fr ST01 has the coating only on the inside. Angiography was performed Through the radial approach using a tiger catheter. (Terumo, Japan) Catheterization and Cardiovascular Interventions 76:919–923 (2010)

KIWAMI ST01 Angiography was performed Through the radial approach using a tiger catheter.

Peripheral balloon anchor method Balloon used for predilatation to the most distal portion of the lesion. Inflated and used as the anchor KIWAMI is inserted slowly toward inflated anchoring balloon. Not to dilate the balloon at the healthy portion Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter. Cypher (3.0 × 18 mm)

5-Fr ST01 allows any BMS and DES KIWAMI effective for stents with a diameter up to 3.0 mm for Cypher and TAXUS Liberte, 3.5 mm for Endeavor Most of BMS can be deployed using KIWAMI except DRIVER (Medtronic) Angiography was performed Through the radial approach using a tiger catheter.

Tips and tricks for stent delivery Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS) Angiography was performed Through the radial approach using a tiger catheter.

Buddy Wire & Buddy Balloon Provide the guiding catheter stability Straighten the tortuous segment of the artery Deflect the stent delivery system away from the calcified area Angiography was performed Through the radial approach using a tiger catheter.

Buddy Balloon Angiography was performed Through the radial approach using a tiger catheter.

Inflated Buddy Balloon LMS / ostial LCX Predilated 2.5 X 15 mm balloon 3.5 X 10 mm cutting balloon LAD 1.25, 1.5 bur Angiography was performed Through the radial approach using a tiger catheter.

4.5 X 32 mm Liberty could cross 3.5 X 20 mm balloon Buddy wire Buddy balloon (3.5 X 20 mm) Inflation of the buddy balloon to 2 atm, the distal stent edge was deflected enough from the plaque to allow its passage Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

3.0/14-mm balloon was placed at the lesion, SES was placed at the proximal lesion. Just after balloon deflation, SES was delivered to the lesion easily. Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Tips and tricks for stent delivery Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile Angiography was performed Through the radial approach using a tiger catheter.

Anchor wire Angiography was performed Through the radial approach using a tiger catheter.

Stent delivery still impossible Angiography was performed Through the radial approach using a tiger catheter. 1.25, 1.5 mm bur 3.0 X 15 mm predalation Stent delivery still impossible

Then a 3.5 x 18 mm Xience V was advanced to distal RCA. Angiography was performed Through the radial approach using a tiger catheter. Deployment of a 3.5 x 23 mm Xience V in the proximal-mid RCA jailing the support buddy wire. Then a 3.5 x 18 mm Xience V was advanced to distal RCA.

Angiography was performed Through the radial approach using a tiger catheter.

Anchor balloon Anchor in side branch Anchor in same artery Angiography was performed Through the radial approach using a tiger catheter. Anchor in side branch Anchor in same artery

Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Super anchor balloon Angiography was performed Through the radial approach using a tiger catheter.

Tips and tricks for stent delivery Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS) Angiography was performed Through the radial approach using a tiger catheter.

Angiography was performed Through the radial approach using a tiger catheter.

Tips and tricks for stent delivery Guiding catheter Increase size / extra-support shape Deep seated Inner catheter Wire & balloon Stiffer wire Buddy wire / balloon Anchor wire / balloon Plaque modification Rota / cutting balloon Stent Shorter / flexible / small profile(BMS) Angiography was performed Through the radial approach using a tiger catheter.

Antegrade PCI used a Fielder and Miracle 3 wire unsuccessful Antegrade PCI used a Fielder and Miracle 3 wire unsuccessful. A large dissection in the RV branch.

A Fielder wire was advanced into the aorta retrogradely. The retrograde balloon (Voyager 2.0 -20 mm) inflated in RCA. Multiple attempts to pass a guidewire antegradely were unsuccessful.

Retrogradely passed a 2.5- 8 mm Mini-Vision stent to the RCA ostium. Subsequently, 5 more Vision stents (2.5-12, 2.5-15, 2.25-12, 2.25-15 and 2.25-23).

Because the patient had previously undergone CABG with the risk of perforation from epicardial collateral passage consequently decreased.

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