1. The First Affiliated Hospital of Harbin Medical University
TRI: How to treat difficult ?
stent or balloon Delivery
Li Yue, M.D.
The First Affiliated Hospital of Harbin Medical University

2. Tips and tricks for stent delivery
Guiding catheter
Extra-support shape/ Increase size
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.

3. 导引导管支撑力
被动支撑
（取决于直径、结构、导管与主动脉壁接触面积和夹角）
主动支撑（术者操作获得）
JL4.0
Deep seating

4. 被动支撑力
直径越大、支持力越强。

5. Radial artery diameter
Angiography was performed Through the radial approach using a tiger catheter.
The frequency of this ratio (≥ 1.0) for 7 and 8 Fr sheaths was 71.5% and 44.9% in male patients and 40.3% and 24.0% in female patients.

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

7. The dosage of heparin, the diameter of radial artery
and the post-procedure compression pressure and
time were independent risk factors for RAO
radial artery internal diameter /
sheath external diameter
4% in patients with ratio >1
13% in patients with ratio <1
Male（mm）
Female（mm） 国外
3.1±0.6
2.8±0.6 魏盟
2.7±0.4
2.3±0.4
贾三庆
2.65±0.60
2.20±0.49
7F sheath external diameter = 3.0mm
Cathet Cardiovasc Diagn 1997;40:156–158

8. ？ 桡动脉细又需强支撑、大内径导引导管怎么办 Sheathless GC system (Asahi Intecc, Japan)
Angiography was performed Through the radial approach using a tiger catheter.
Sheathless GC system (Asahi Intecc, Japan)
hydrophilic GC + central dilator

9. The outer diameter of the 6.5 F sheathless GC (2.16 mm)
is smaller than a 5 F sheath (2.29 mm).
The outer diameter of the 7.5 F sheathless GC (2.49 mm)
is less than that of a 6 F sheath (2.62 mm).
Angiography was performed Through the radial approach using a tiger catheter.
Thicker than conventional guide catheters due to an
addition layer of steel braiding and the hydrophilic coating,
aids backup support.

10. After the diagnostic angiography, the sheath was exchanged for the sheathless catheter over a standard 150 cm J-tipped inch (Terumo®, Japan) wire.
Angiography was performed Through the radial approach using a tiger catheter.

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

12. Comparing the backup force between TFI and TRI
It was found to be 60% greater in TFI with a JL catheter, and 8% greater in TFI with a backup (BL/EBU/XB) type catheter.
JL4.0
J Invasive Cardiol Dec;17(12):636-41

13. 短头Amplatz导管
刮伤主动脉窦情况
大大降低，造成靶血
管撕裂、 夹层可能
降到最低
入冠不深，几乎没有
嵌顿现象 标准 短头

14. Inner catheter 5 in 6 guiding catheter technique
Heartrail II (Terumo, Japan)
long (120 cm) 5 Fr catheter (13 cm very soft end portion)
Absence of curve and the flexibility of its tip permit the
“child” catheter coaxial with the target vessel.
Angiography was performed Through the radial approach using a tiger catheter.

15. 5 mm/s
Filled with water that was kept at 37°C

16. Switching to 5-in-6 system

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

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

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

20. 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.

21. 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.

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

23. 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

24. 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)

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

26. Backup support of GC
Circ Cardiovasc Interv Apr 1;4(2):155-61

27. Trackability of GC Using balloon-anchoring technique
5F child catheter could be advanced to 13.0 cm, whereas the 4F child catheter could be advanced to 15.0 cm (P<0.005).

28. Provided >90% success rate for 51 lesions in which conventional techniques had failed.
Success may be contributed, in most part, by the
trackability of the 4F child catheter.
Does not usually compromise the coronary flow.

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

30. 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.

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

32. 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.

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

34. 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.

35. 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.

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

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

38. 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.

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

40. 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

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

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

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

45. Buddy - in – jail (Distal)

47. Buddy - in – jail (Proximal)

56. 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.

57. ？
旋磨头不能够通过怎么办
Angiography was performed Through the radial approach using a tiger catheter.

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

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

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

61. 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.

62. 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.

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

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

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

66. Seesaw balloon-Wire cutting技术

67. 球囊“挤撬”
反复冲击、扩张
1.25×10mm
纤维帽
circumflex coronary artery in the atrioventricular groove

68. 多导丝挤压
Pilot 50
Pilot 150
circumflex coronary artery in the atrioventricular groove

69. ?
How to do next ×
Mini TREK
1.2×6 mm ×
Sprinter
1.5×6 mm

70. Seesaw balloon-Wire cutting
Pilot 50
Tazuna
1.25×10 mm
Pilot 150
circumflex coronary artery in the atrioventricular groove
Tazuna
1.25×10 mm

71. circumflex coronary artery in the atrioventricular groove

72. 反复“交替”
circumflex coronary artery in the atrioventricular groove

73. circumflex coronary artery in the atrioventricular groove

74. circumflex coronary artery in the atrioventricular groove

75. Technique Features and PCI Results
Results (n = 21)
Procedure success related to Seesaw balloon-wire cutting technique, n (%)
16 (76.2%)
Technical failure, n (%)
5 (23.8%)
Due to inability to place a second guidewire
1 (4.8%)
Due to balloon unable passing
4 (19.0%)
Category of the second guidewire, n (%)
Pilot 150
9 (42.8%)
Pilot 200
8 (38.2%)
Progress 200T
Mean time of successful Seesaw balloon-wire cutting procedure (mean ± SD, min)
26.4 ±7.7
Application of additional technique, n (%)
Rotational atherectomy with Rotablator, n (%)
3 (14.3%)
Overall procedure success, n (%)
19(90.5%)
Seesaw balloon-wire cutting technique related serious complication, n(%)

76. Tips and tricks
Polymer-coated and more stiff guidewire (pilot 150 or 200， Progress 200T）as the second guidewire.
Short and low profile balloons (1.25×10mm tazuna) are recommend .
More suitable for TRI or GC without
enough back-up support

78. JR JL AL AL BL3.0

80. Tazuna
1.25×10 mm

81. Buddy-in-Jail

84. Tornus

87. One month later

88. Journal of Invasive Cardiology
Seesaw balloon-Wire cutting技术
Journal of Invasive Cardiology

89. Thanks !