Guias y Cateteres Guias y Cateteres GuiaGuia

Carlos E UribeCarlos E UribeClinica Cardiovascular Santa Clinica Cardiovascular Santa

MariaMariaMedellinMedellinColombiaColombia

Reglas de OroReglas de Oro

Guia adelante del Guia adelante del catetercateter

Manipulacion en el Manipulacion en el arco aorticoarco aortico

Back Flush Back Flush vigorosovigoroso

Coaxial a la arteria Coaxial a la arteria a tratar.a tratar.

Curvas GeometricasCurvas Geometricas

Mamario Corto ??Mamario Corto ??

Soluciones:Soluciones:

1.1. Mamarios de 90 cms (disponibles)Mamarios de 90 cms (disponibles)1.1. Cambio engorrosoCambio engorroso

2.2. Sobre guia 0.035 de intercambio (300).Sobre guia 0.035 de intercambio (300).

Técnica de acortamiento Técnica de acortamiento modificadamodificada

Cortar el catéterCortar el catéter Adición de introductor (tecnica Adición de introductor (tecnica

griega…)griega…)

Técnicas de Inflado del Técnicas de Inflado del Balón:Balón:

Inflado rápido vs. Inflado Inflado rápido vs. Inflado lento ???lento ???

Coronary dissection resulting from angioplasty with slow oscillating vs. rapid inflation and slow Coronary dissection resulting from angioplasty with slow oscillating vs. rapid inflation and slow vs. rapid deflation.vs. rapid deflation.Cathet Cardiovasc Diagn. 1995 Mar;34(3):202-9. Cathet Cardiovasc Diagn. 1995 Mar;34(3):202-9. PMID: 7497485 [PubMed - indexed for MEDLINE]PMID: 7497485 [PubMed - indexed for MEDLINE]Blankenship JCBlankenship JC, , Krucoff MWKrucoff MW, , Werns Werns SWSW, , Anderson HVAnderson HV, , Landau C et al…Landau C et al…

Department of Cardiology, Geisinger Medical Center, Penn State Geisinger Health System, Department of Cardiology, Geisinger Medical Center, Penn State Geisinger Health System, Danville 17822, USA. jblankenship@PSGH5.eduDanville 17822, USA. jblankenship@PSGH5.edu

Previous studies suggest that slow and/or oscillating balloon inflation during coronary Previous studies suggest that slow and/or oscillating balloon inflation during coronary angioplasty may decrease the incidence of coronary dissection and improve clinical angioplasty may decrease the incidence of coronary dissection and improve clinical outcomes. To compare the effect of slow oscillating versus conventional fast inflation outcomes. To compare the effect of slow oscillating versus conventional fast inflation techniques on the incidence of severe coronary dissection during angioplasty, 622 patients techniques on the incidence of severe coronary dissection during angioplasty, 622 patients were randomized to slow oscillating inflation versus fast inflation. Angiographic outcomes of were randomized to slow oscillating inflation versus fast inflation. Angiographic outcomes of the procedures and in-hospital clinical events were recorded. The primary end point of the procedures and in-hospital clinical events were recorded. The primary end point of severe (type C, D, E, F) dissection occurred in 7.7% of patients undergoing slow oscillation severe (type C, D, E, F) dissection occurred in 7.7% of patients undergoing slow oscillation and 6.6% of patients undergoing fast inflation (p = 0.87). Major complications (death, and 6.6% of patients undergoing fast inflation (p = 0.87). Major complications (death, urgent coronary artery bypass graft surgery, stroke, abrupt closure, or Q-wave myocardial urgent coronary artery bypass graft surgery, stroke, abrupt closure, or Q-wave myocardial infarction) occurred in 4.7% of patients undergoing slow oscillation and 3.5% of patients infarction) occurred in 4.7% of patients undergoing slow oscillation and 3.5% of patients undergoing fast inflation (p = 0.45). The 2 inflation strategies did not differ in the pressure undergoing fast inflation (p = 0.45). The 2 inflation strategies did not differ in the pressure at which the balloon achieved full expansion, angiographic success rate, residual stenosis, at which the balloon achieved full expansion, angiographic success rate, residual stenosis, and incidence of all minor and/or major complications. We conclude that there is no benefit and incidence of all minor and/or major complications. We conclude that there is no benefit of slow oscillating inflation over routine fast inflation in angioplasty. Slow oscillating of slow oscillating inflation over routine fast inflation in angioplasty. Slow oscillating inflation did not dilate lesions at lower pressures, decrease the incidence of dissection or inflation did not dilate lesions at lower pressures, decrease the incidence of dissection or severe dissection, or reduce the incidence of adverse clinical outcomes.severe dissection, or reduce the incidence of adverse clinical outcomes.

: Am J Cardiol. 1994 Feb 1;73(4):228-30. Links Does the speed of balloon deflation affect the complication rate of coronary angioplasty?Foster CJ, Teskey RJ, Kells CM, O'Neill BJ, Fitzgerald N, Foshay K, Peck C. Division of Cardiology, Victoria General Hospital, Halifax, Nova Scotia, Canada.Two hundred consecutive coronary arteries in 157 patients undergoing angioplasty were randomized to fast or slow balloon deflation. Angioplasty was successful in 188 cases (101 with slow and 87 with fast deflation). There was no significant difference between the 2 groups with regard to the total number of dissections, although there was a greater number in the slow deflation group, and no difference in the number of minor dissections (National Heart, Lung, and Blood Institute types A and B). There was a significantly greater number of more severe dissections (types C to F) in the slow deflation group (20 vs 5; p = 0.013). It is proposed that the greater number of severe dissections is due to either increased turbulence or movement of the partially deflated balloon during slow deflation. Thus, slow balloon deflation during coronary angioplasty is associated with a higher complication rate than is conventional rapid deflation.PMID: 8296751 [PubMed - indexed for MEDLINE]

GuiasGuias

Guias de Segunda y Guias de Segunda y Tercera GeneracionTercera Generacion

HydrophylicChoice-PT(BSC)

Stiff SpringMiracle Bros (Abbott)Cross-It (Guidant)

Stiff HydrophylicShinobi (Cordis)PT Interm. (BSC)

TecnicasTecnicas

AnterogradaAnterograda RetrogradaRetrograda Tecnica de una sola guiaTecnica de una sola guia Tecnica de Doble guiaTecnica de Doble guia

Inyeccion Contralateral.Inyeccion Contralateral.

Seleccion de la GuiaSeleccion de la GuiaConsideraciones a la hora de seleccionar una guia.Consideraciones a la hora de seleccionar una guia.

1.1. Respuesta al torqueRespuesta al torque2.2. La punta (respuesta tactil)La punta (respuesta tactil)3.3. Forma de la curvaForma de la curva

Guias HidrofobicasGuias Hidrofobicas Mejor respuesta tactil al operadorMejor respuesta tactil al operador Mejor respuesta y Navega mejor por micro canalesMejor respuesta y Navega mejor por micro canales Mejor penetracion en la capa fibrosa “mas nobles”….Mejor penetracion en la capa fibrosa “mas nobles”….

Guias HidrofilicasGuias Hidrofilicas Menos feedback tactil al operador, se introduce mas Menos feedback tactil al operador, se introduce mas

facilmente por disecciones, microcanales etc…facilmente por disecciones, microcanales etc… Menos control de la punta, siguen el paso de menor Menos control de la punta, siguen el paso de menor

resistencia.resistencia.

Success Success

with precision & with precision & controlcontrol

Asahi Confianza Wire Asahi Confianza Wire

ConfianzaConfianza The Confianza is specifically designed for HSL that may require a higher The Confianza is specifically designed for HSL that may require a higher

penetration ability than the Miraclebros. penetration ability than the Miraclebros.

Coil tip diameter tapers down from 0.014” to 0.009” to seek micro Coil tip diameter tapers down from 0.014” to 0.009” to seek micro channels/dimples in HSLchannels/dimples in HSL

Tip stiffness, 9.0g Tip stiffness, 9.0g

Radiopacity = 20 cmRadiopacity = 20 cm Visibility of full wire length, advantageous in HSLVisibility of full wire length, advantageous in HSL

Tip diameter tapers down to 0.009”

Note: Wire images are not to scale.

Asahi Miraclebros Asahi Miraclebros

Miraclebro Family 3.0, 4.5, and 6.0Miraclebro Family 3.0, 4.5, and 6.0

Smooth tractability & delivery Smooth tractability & delivery with Joint-less spring coilswith Joint-less spring coils

Core-to-tip design Core-to-tip design

Excellent tip shapeability & shape Excellent tip shapeability & shape retention retention

Incremental tip stiffness and wire Incremental tip stiffness and wire supportsupport

3.0, 4.5 and 6.0 grams of 3.0, 4.5 and 6.0 grams of forceforce

Radiopacity = 11cmRadiopacity = 11cm Visibility of full wire length, Visibility of full wire length,

advantageous in HSLadvantageous in HSL

Miraclebros3

Miraclebros4.5

Miraclebros6

Support & Tip Stiffness

Least

Greatest

Note: Wire images are not to scale.

TORNUSTORNUS