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

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

36. Admission 3: Left iliac artery CTO recanalisation

37. Right iliac artery CTO recanalisation

38. Aortography

41. 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

42. Thank You !!