PCI & AimRadial 2018 | Even the big boss fail - Zoltán Ruzsa

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  1. „Even the big boss fail” Zoltán Ruzsa MD PhD 2. Admission 1 -Clinical data ã Clinical data ã Hyperlipidemia ã Hypertension ã Significant PAD (2002 ABB)…
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  • 1. „Even the big boss fail” Zoltán Ruzsa MD PhD
  • 2. Admission 1 -Clinical data • Clinical data • Hyperlipidemia • Hypertension • Significant PAD (2002 ABB) • Previous stroke (left CCA occlusion) • previous carotide angio from right radial access (2010.09) • CAD (non significant lesions)- • previous coronary angiography from right radial access (2011.12) • Critical hand ischemia (rest pain) • Intermittent claudication (WD 50m) • Physical examination • No brachial, radial and ulnar pulse • No ulcer or gangrena on the right hand • No palpable femoral arteries • Intitial medical therapy • ASA 1x100 mg, Clopidogrel 1x75 mg, Rosuvastatin 10 mg/die • Antihypertensive treatment • Stop BBlocker
  • 3. Diagnostic angiography
  • 4. Diagnostic angiography
  • 5. Intervention plan • Left radial artery access with 5F sheath • Simmons 2 catheter 5F • Hydrophilic Terumo 0.035 260 cm GW • 6-7F 90 cm Cook sheath • Ballon angioplasty of the brachial artery Left brachial artery recanalisation
  • 6. Failed right subclavian artery cannulation from left radial access
  • 7. Ulnar artery puncture under fluoroscopy
  • 8. Retrograde subintimal brachial artery recanalisation Ballon support, luminal recanalisation Balloon support, subintimal recanalisation
  • 9. Balloon dilatations of the brachial artery After balloon dilatation
  • 10. Stenting of the brachial artery Changing the 0.014 GW for Jindo ES 0.035 Positioning of the stent After stent deployment Stent postdilatation
  • 11. Final angiography Non-occlusive pressure bandage
  • 12. Second day….presentation • 5P- pulseless, pain, prostration, paresis, pale • No radial and ulnar pulse • Pulsoxymetry: O2 saturation <50%
  • 13. Urgent angiography from left radial access Brachial stent thrombosis
  • 14. Procedure plan Left brachial artery recanalisation • Left radial artery access with 5F sheath • Simmons 2 catheter 5F • Hydrophilic Terumo 0.035 260 cm GW • 6-7F 90 cm Cook sheath • Anchoring technique • Loop technique • Ballon angioplasty of the brachial artery
  • 15. Cannulation of the left subclavian artery from the left radial artery 1. Simmons 2 catheter and Terumo wire 2. Pushing down the catheter and loop formation in the aorta 3. Advancing the wire in the stent
  • 16. Cannulation the left axillary artery 1. Intubation the left axillary artery with budy wire 260 cm support (Jindo, Terumo) 2. Passing the stent with Terumo wire
  • 17. Ballon angioplasty of the stent thrombosis Balloon angioplasty of the stent
  • 18. Angiography after angioplasty Brachial dissection Radial art. Interosseal art.
  • 19. Stenting of the brachial dissection 1. Subintimal pattern 2. Positioning of the stent 3. After stent 4. Postdilatation
  • 20. Angiography after the second stent
  • 21. Anterograde ulnar artery angioplasty Outflow track recanalisation
  • 22. Radial artery puncture under fluoroscopy Retrograde radial art. puncture
  • 23. Retrograde radial artery recanalisation 1. Retrograde GW passage 2. Retrograde ballooning 3. Reentry
  • 24. Radial and ulnar artery angioplasty
  • 25. Final angiography
  • 26. Control angiography (2 months)
  • 27. BUT at 2 years FU patient presented with a - CHI (right hand- rest pain and severe Raynaud) - CLI (left limb- rest pain, right limb- gangrena) - UA (rest pain) Access ?? - Right and left iliac (occluded) - Right radial, brachial, ulnar occl - Left radial occluded
  • 28. Angiography: Brachial artery stent occlusion
  • 29. Cannulation of the left subclavian artery
  • 30. Stent CTO recanalisation
  • 31. Admission 3: Left iliac artery CTO recanalisation
  • 32. Right iliac artery CTO recanalisation
  • 33. Aortography
  • 34. Conlusion • 1. Long term patency of the forearm interventions are unknown • Primarly use DEB • Implant a DES in the forearm if necessary • Stent fracture can occure also • 2. Stent CTO recanalisation in the forearm is as hard as in lower limb segment • Iliac artery recanalisation after ABB can be complicated with perforation/rupture and failure due to presence of severe scaar in the pelvis
  • 35. Thank You !!
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