The PIERCE technique for recanalization of heavily calcified arteries in hemodialysis patients.
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1 The PIERCE technique for recanalization of heavily calcified arteries in hemodialysis patients. Tomoyasu Sato ( tomoyasu_satou@yahoo.co.jp ) Department of interventional and diagnostic Radiology Tsuchiya general hospital, Hiroshima, JAPAN
2 Disclosure Speaker name: Tomoyasu Sato I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
3 Heavy calcification is one of the most challenging lesion characteristics for EVT especially HD pats. Difficulty in wire penetrating of calcified CTO. device crossing or dilating the lesions.. long time patency. Guide wires,catheters Bidirectonal approach Crossing devices PIERCE technique Drug solutions
4 We often experience these cases in HD patients. Case: 63y.o. male: DM, HT, 10 years history of hemodialysis Intractable toe ulcers of both foot. SPP = 25mmHg. Some unfavorable dilatation due to calcification even though guidewire has passed. SterlingES 1.5mmx20 Unable to dilate even in high pressure No device passage No device passage PRE CTA SHIDEN 2mmx20 25 atom POST
5 In Japan, most of the debulking devices for calcified lesions are not available except Crosser. Crosser Jetstream Phenix Excimerlaser Rotablader Diamondback360
6 We hit on the " PIERCE technique " : ( Percutaneous direct needle puncture of calcified plaque during recanalization of heavily calcified plaques) Ichihashi S, Sato T. et al: J Vasc interv Radiol 2014; 25: Percutaneous cracking of heavily calcified plaques. Enables catheter passage or lesion dilatation. Required Device: 21G to 16G needle Required device 18G needle 16G inner needle of Venula Merit: Easy to perform. Extremely inexpensive. Simple and inexpensive procedure
7 Contents I. Basic concept and technique of the PIERCE technique. 2. Tips and tricks which enhance the effects of the PIERCE technique.
8 Schema of the PIERCE technique ( Percutaneous direct needle puncture of calcified plaque during recanalization of heavily calcified plaques) Ichihashi S, Sato T. et al: J Vasc interv Radiol 2014; 25: Severely calcified plaque Cracks PIERCE Though CTO wire has crossed, any balloon or microc-atheter does not cross. PIERCE is done. Microcatheter or balloon can cross.
9 Representative PIERCE cases: Case 1. Case 1: 75 years old female Lt. toe gangrene ( Rutherford 5 ) 15 years of history of hemodialysis due to diabetic nephropathy
10 Case 1: 75 years old female Lt. toe gangrene ( Rutherford 5 ) 15 years of history of hemodialysis due to diabetic nephropathy CTO with massive calcification (4mmx40mm 27atm) Anable to dilate due to circumferential calcification. After the PIERCE, Dilated successfully
11 Representative PIERCE cases: Case 2. Case 2: 84 y.o. female HD, DM, un-healing ulcer of her Rt. foot. Iliac arterial stenting was done 2 weeks ago. SPP was not improved. Additional PTA was planned.
12 Case 2: 84 y.o. female HD, DM, unhealing ulcer of Rt. foot. ATA was punctured. A 4F introducer was inserted. Bidirectional wiring was done A wire could cross. Any device could not cross the calcification.
13 The lesion was so hard that we put the needle on an syringe to achieve firm grip. After the PIERCE technique, device passage was obtained and stent was placed entire SFA. A syringe enables firm grip and high destructive performance of the needle. PIERCE was done After stent
14 Representative PIERCE cases: Case 3. Case 3: 70 years old male patient. 10 years of history of hemodialysis due to diabetic nephropathy. Intractable ulcer in his right 3rd,4th finger and heel (Rutherford 5 ). We intended to recanalize PTA because of the heel ulceration.
15 Case 3: 70 years old male patient. Intractable ulcer in his right 3rd,4th finger and heel (Rutherford 5 ). We intended to recanalize PTA because of the heel ulceration. Pre A guide wire has passed lateral plantar arch and made it pull-through. Microcatheter could not cross the orifice of lateral planter artery.
16 The PIERCE was done. After the PIERCE, a balloon could cross the lesion. Final angiogram
17 Results Between May 2012 and December 2017, 14 cases, 16 legs were tried to recanalize by the PIERCE technique. Failed device passage was seen in 2 lesions. We experienced a case of severe hemorrhage of ATA who need embolization by gelatin sponge.
18 Contents I. Basic concept and technique of the PIERCE technique. 2. Tips and tricks which enhance the effects of the PIERCE technique.
19 1. Use adequate needles: Big needles such as 18G or more is needed for the good results. Small needles can penetrate the plaque but can not create the crack. Tip of the poking needle is easy to become dull. Only one or two puncture would be available. Several needles should be used for one procedure. Required device 18G needle 16G inner needle of Venula Simple and inexpensive procedure
20 2. Poke and rotate: crack
21 3. Fix the target artey: The target lesion is often slippery. Fixation needle Fixation needle Fixation needles X X X X Puncture needle Puncture needle
22 Take home messages Recanalization of heavily calcified arteries is still challenging. By dedicated guidewires and crossing catheters, success rate is improving even in conventional procedures. PIERCE technique requires only commonly used needles and is extremely low cost compare to the crossing or debulking devices. To know some technical TIPS is highly required for successful procedure. PIERCE technique still plays an important role during recanalization of heavily calcified arteries.
23 Thank you for your attention. Tomoyasu Sato ( tomoyasu_satou@yahoo.co.jp ) Department of interventional and diagnostic Radiology Tsuchiya general hospital, Hiroshima, JAPAN
24
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