S f l C l C tidSuccessful Complex Carotid Bifurcation Angioplasty-ParallelBifurcation Angioplasty-Parallel

Wire Techniqueq

Dr Kapardhi P. L. N MD,DMDr Kapardhi P. L. N MD,DMDr Kapardhi P. L. N MD,DMDr Kapardhi P. L. N MD,DM

Senior interventational cardiologist,Senior interventational cardiologist,Senior interventational cardiologist, Senior interventational cardiologist, Director of Stem cell therapy Director of Stem cell therapy

programme ,Global Hospital Hyderabad programme ,Global Hospital Hyderabad INDIAINDIAINDIA .INDIA .

Cli i l filCli i l filClinical profile Clinical profile

•• A 72 Yrs , Gentleman A 72 Yrs , Gentleman Ri k F tRi k F t HTN DMHTN DM•• Risk Factors Risk Factors –– HTN ,DM HTN ,DM

•• Chest pain & Dyspnea at restChest pain & Dyspnea at rest•• ECGECG-- Inferolateral NSTEMI Inferolateral NSTEMI •• 2 D ECHO2 D ECHO ––RWMA Mild LV systolic dysfunctionRWMA Mild LV systolic dysfunction•• 2 D ECHO 2 D ECHO RWMA ,Mild LV systolic dysfunctionRWMA ,Mild LV systolic dysfunction•• CAG CAG –– TVD TVD

PLANPLAN CABGCABG•• PLAN PLAN –– CABG CABG

C t’dC t’dCont’dCont’d

•• Pre CABG Evaluation Pre CABG Evaluation –– CT Angio revealed CT Angio revealed 90 % A l t d Bif ti l ft90 % A l t d Bif ti l ft90 % Angulated Bifurcation left common 90 % Angulated Bifurcation left common carotid lesion carotid lesion

•• Planned for carotid angioplasty prior to Planned for carotid angioplasty prior to CABGCABGCABGCABG

CTAngio Showing 90 % Angulated LCC bifurcation Lesion

CTA i Sh i 90 % A l t d LCC bif ti L iCTAngio Showing 90 % Angulated LCC bifurcation Lesion (still image)

P dP dProcedure Procedure RFA A hRFA A h•• RFA Approach RFA Approach

•• 7 Fr long sheath (Cordis ) 7 Fr long sheath (Cordis ) g ( )g ( )•• Guide Wire Guide Wire –– BMW 0.014” X190 cmsBMW 0.014” X190 cms•• Acute vessel closureAcute vessel closure•• Acute vessel closure Acute vessel closure •• Whisper 0.014 “ x 190 cms in to External Whisper 0.014 “ x 190 cms in to External

d ( CC)d ( CC)carotid (ECC)carotid (ECC)•• Predilatation Predilatation –– CTO Balloon 1.1x10 CTO Balloon 1.1x10

mm ,To alter the lesion geometry mm ,To alter the lesion geometry

•• ByBy doubledouble wirewire technique,technique, thethe secondsecondwhisperwhisper wirewire withwith largelarge secondarysecondary curvecurve waswaswhisperwhisper wirewire withwith largelarge secondarysecondary curvecurve waswasnegotiatednegotiated successfullysuccessfully intointo ICCICC..

•• SubsequentlySubsequently underunder SpiderSpider protectionprotection devicedevice•• SubsequentlySubsequently underunder SpiderSpider protectionprotection devicedevice(( 66 mmmm ,, IVTIVT )) PRECISEPRECISE ((CordisCordis )) stentstent77xx4040 mmmm waswas deployeddeployed withwith 66xx1212 mmmm77xx4040 mmmm waswas deployeddeployed withwith 66xx1212 mmmmballoonballoon postpost stentstent dilatationdilatation..ObtainedObtainedgoodgood resultresultgoodgood resultresult

(1)(2)

(3) (4)

Double wire techniqueDouble wire technique(5)

(6)

(7)(8)

(10)(9)

(10)

(11)(12)

SSSummary Summary

•• Bifurcation with 90 angulated lesion is a Bifurcation with 90 angulated lesion is a complex lesion subset of carotid angioplastycomplex lesion subset of carotid angioplastycomplex lesion subset of carotid angioplasty complex lesion subset of carotid angioplasty

•• Most difficult step is guide wire navigation into Most difficult step is guide wire navigation into ICCICCICC ICC

•• Changing the geometry of lesion by low profile Changing the geometry of lesion by low profile balloon dilatationballoon dilatationballoon dilatation balloon dilatation

•• Hydrophilic wire with large secondary curve Hydrophilic wire with large secondary curve mounted on OTW balloon facilitates wiremounted on OTW balloon facilitates wiremounted on OTW balloon facilitates wire mounted on OTW balloon facilitates wire crossing across the lesion for successful resultscrossing across the lesion for successful results