parallel sheath technique

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


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)


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


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.


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


Five Cases

The common bail-out technique for all cases was parallel sheath technique

Two extra-stiff 0.035” wires


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


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.


© 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


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


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


© 2

014

Eur

oInt

erve

ntio

n. A

ll rig

hts

rese

rved

.


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.


© 2

014

Eur

oInt

erve

ntio

n. A

ll rig

hts

rese

rved

.



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).


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.



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


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.


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.


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


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%


parallel sheath technique

Health & Medicine