Things we use in the catheter lab: Catheters, wires, balloons, stents, devices. Shakeel A Qureshi Evelina Children s Hospital London

Transcription

1 Things we use in the catheter lab: Catheters, wires, balloons, stents, devices Shakeel A Qureshi Evelina Children s Hospital London SCAI Interventional Course, Las Vegas, December 2011

2 Disclosures Consultancy agreements NuMED Inc, Proctor for: AGA Medical (St Jude Medical) Medtronic

3 Acknowledgements: Soo Boolkah Nick Hayes

4 Basic Equipment Sheaths Guidewires Catheters Guiding catheters Balloons Coils Occlusion devices Stents Covered stents Retrieval kit

5 Sheaths Selection of sheaths from 3-12 Fr May occasionally need 14 Fr sheath Occasionally will need >18 Fr sheath Short sheaths and long sheaths

6 Guidewires J-tip Straight Size: 0.014, 0.018, 0.021, 0.025, 0.035, Length: 150 cm 260 cm Type: Teflon-coated, hydrophilic (Terumo), standard, floppy, stiff, extra-stiff, super-stiff (Amplatzer, Rosen, Lunderquist) Terumo wire is the most slippery one (used for vessels with many curves) Stiffest wires used for sheath placement for devices, stents, valves

7 Long sheaths Mullins Flexor Shuttle Hausdorf

8 Long Sheaths Used for stents/devices implantation Sheath + Dilator Side arm + haemostatic control Radio-opaque band near tip, not at the tip

9 Kink resistant sheaths Sheaths can kink, so need to have kink-resistant sheaths TorqueVue Torque control Kink resistance Sheath radio-opacity

10 Kink-resistant sheaths Flexor Ansell sheath 4 Fr to 7 Fr and 45cm-90cm-110cm and guide wire Flexor sheath 10-12Fr wire length of 80/90cm Shuttle sheath 4 Fr to 8 Fr 4-5 Fr accepts both and guide wire. 6-8Fr accepts 0.38 guide wire 4-5Fr sheath length is 90/ sheath length is 80/90

11 Catheters All types of catheters Basic ones : multipurpose (GL), pigtail, NIH, Cobra, Judkins coronary catheters, Multitrack, Tracker-18 or Ferret, Progreat (3 Fr) Tapered and non-tapered catheters Determine own favourite catheters Become familiar with their use

12 Variety of sizes, shapes & curves Catheters

13 Multipurpose End-hole catheters Cobra Judkins right coronary Judkins left coronary Amplatz right coronary Multipurpose catheter the mainstay of paediatric cardiac catheterisation

14 Berman or balloon wedge (4-8 Fr) Angiographic catheters Multitrack Pigtail Multitrack catheter useful for pressure measurement without loss of position and angiography without recoil of catheter 3 6 Fr shaft, 4-8 Fr sheath needed

15 Balloon catheters Advanced over the wire to the target vessel/valve Profile: Catheter shaft (Tyshak-mini passes through 3-4 Fr sheath) Balloon length ranges from 1 cm to 6 cm) Balloon size ranges from 1.5 mm to 30 mm and beyond Fast inflation/deflation time Compliant, semicompliant, non-compliant Inflation without bursting Low-pressure balloons burst at < 5 atm (e.g Tyshak) High-pressure balloons burst at > atm (e.g Z-Med, Mullins, Powerflex, Coefficient, Cristal, Advance, Atlas)

16 Balloons markers

17 Tyshak mini Balloons Tyshak balloons - lower profile smaller sheath, but lower burst pressure Tyshak Mini - Lowest profile balloon (3-4Fr introducer) 4 10mm diameter 2cm long (4 10mm) Tyshak Tyshak 2 4cm long (9 10mm) Tyshak 2 25mm diameter 1 10cm length Tyshak II 4 30mm diameter 2 10cm length

18 BiB Balloon Inner balloon - Tyshak II (1/2 diameter of outer and 1 cm shorter) Outer balloon - Z-Med (high pressure) 8 24mm diameter cm length 2-5 atm pressure Allows controlled delivery of stents Allows adjustment of stent position after inflation of inner balloon Balloon design prevents flaring of stent

19 Mullins Coefficient Atlas Powerflex Z-Med Advance High pressure balloons

20 Mullins X Very high pressure (>16 atm) mm diameter 3 4 cm length Large profile

21 Z-Med I & II High pressure balloon Z-Med II higher pressure with larger introducer sheath Z-Med 2 40 mm diameter 2 6 cm length Z-Med II 4 30 mm diameter 2 10 cm length

22 COEfficient balloon Low profile, higher pressure (8-10 atm) guidewire 4 12mm diameter 2 4cm length

23 Advance 18LP balloon High pressure balloon Nominal pressure of 8 atm and burst pressure is 14 atm 3 8 mm diameter Length 2 10 mm 4Fr sheath except >8mm diameter which needs 5 Fr sheath Shaft lengths 80cm/135cm Powerflex balloon 4 12mm diameter 2 6cm length guidewire

24 Cutting balloons used for highly resistant stenosis Diameter 5, 6, 7 & 8mm Length 2cm 7Fr sheath

25 Sizing balloons AGA - diameters 18, 24 & 34 mm, length 3.5, 4.5 & 5.5 cm NuMED Fr sheath, mm diameter, 3 5 cm length

26 Septostomy balloons Miller (1.8 ml 6 Fr sheath, 4 ml 7 Fr sheath) Z-5 septostomy balloon (9.5mm over guidewire, 13.5mm over )

27 Stent implantation Selection of guidewires e.g superstiff Selection of balloons of appropriate size and length Selection of appropriate length and diameter stents

28 made of: Stainless steel 316L used for balloon-expandable stents Cobalt-based steels (Wallstent made from cobalt alloyed with chromium and molybdenum) Tantalum Platinum (alloyed with iridium or tungsten CP) Nickel-titanium alloys Polymers Stents Biodegradable materials

29 Self-expanding - Wallstent Made of nitinol or cobalt-chromium alloy Very flexible Low profile Cannot be crushed Conform to the curvature of vessel Less radial strength than balloon expandable stents

30 Balloon-expandable - allow for further expansion of the stent as the patient grows Advantages: Reliable expansion Further expansion in future Good radial strength but rigid Accurate positioning Less foreshortening Long history of use and experience Bare and covered stents available Disadvantages: Stents Stiff Require relatively larger delivery systems

31 Stents Balloon-expandable stents: Small - expandable to 4-5 mm diameter used in coronary arteries and other peripheral vessels No use in paediatrics except in ducts Medium - expandable to mm diameter Large -expandable to 18 mm diameter Extra large - expandable to 25 mm diameter

32 Small diameter stents Huge variety of coronary stents used in vessels eg PDA Liberte stent

33 Stents Balloon expandable stents : Palmaz Palmaz Genesis Intrastent Andrastent Cheatham-Platinum (bare and covered) Jostent (bare and covered) V12 Atrium (bare and covered)

34 Stents Closed cell Palmaz generations: Corinthian, Genesis Cheatham-Platinum Jomed peripheral On expansion cells maintain consistent shape Cell geometry consistent and cells complete

35 Palmaz Genesis / Blue Non-premounted Lengths 19, 29, 39 & 59mm Diameter 10 12mm Premounted Lengths 12, 15, 18 & 24mm Balloons 4 7 mm

36 Stents Intrastent Doublestrut LD Jomed Wavemax AVE Bridge Herculink Omnilink Andrastent Open cell

37 Intrastent - LD Doublestrut Mega / Max Open cell Flexibility, radial strength Length 16, 26, 36mm (Doublestrut up to 56 & 76mm)

38 Andrastent Cobalt chromium stent, open cell 2 different types - XL and XXL Recommended sheath for the XL stent is 8-9 Fr, for XXL stent is 10-11Fr XL stent length from mm XXL stent from 17mm to 57mm long Range of dilatation of XL stent is 14mm-25mm in diameter Range of dilatation of XXL 20mm-32mm in diameter Open cell XXL

39 Covered Stents Gore Cook Jomed NuMed Atrium

40 Covered stents Premounted CP (bare and covered) Atrium (bare and covered)

41 Cheatham-Platinum (CP) stent Bare metal or Covered Lengths 16, 22, 28, 34, 39 & 45mm Premounted on mm BIB available Degree of shortening depends on inflation diameter

42 Advanta V12 covered (Atrium) Advanta V12 covered stent 5 10mm diameter 16, 22, 38, 59 mm length Large diameter V12 12, 14 & 16mm 29, 41 & 61mm length

43 Snares for circuits and catheter retrieval Embolised central line/cannula (oncology patient) Embolised catheter/balloon fragment Embolised/broken wire fragment Embolised devices Coil Various types of occluders Stents

44 Amplatz Gooseneck Snare (Microvena) Long track record and very commonly used Snare opens at right angles to catheter Robust Sizes from 4-35 mm diameter

45 Entrio Snare (Bard) Triple loop retrieval system Made from super-elastic Nitinol, flexible, kinkresistant, steerable for tortuous vessels, 1:1 torque control Interwoven platinum strands for better visibility Useful for wide range of lumens Interlaced loops for better capture and grip Catheter tip has 15º angle plus tip marker

46 Multi-snare (Pfm) Dual-plane snare system to increase chance of grasping Variable loop diameter - versatile Flexible nitinol with high tensile strength Low profile introducer Sizes from 2 30 mm diameter Catheter 3, 4, 5 or 6 Fr with tip marker

47 Vascular Retrieval Forceps (Cook) 3 Fr diameter Soft wire tip to guide without trauma Sharp serrated forceps for strong grip

48 Dotter/Dormier basket Biopsy forceps

49 Devices for ASDs Amplatzer Cardioseal or Starflex (no longer available) Helex Atriasept Several others Helex Cardioseal Starflex Amplatzer

50 Amplatzer Septal Occluder Self-expandable Self-centering double disc with short-connecting Waist Nitinol wire mesh Polyester fabric fills the waist and discs Sizes: 4-40 mm - Waist 4 20mm (1mm increments) Waist 20 40mm (2mm increments) 6 12F sheath Cribriform 18, 25, 30, 35 & 40mm 8 10F sheath

51 HELEX Septal Occluder (Gore) Two discs formed by one continuous wire in the shape of a spiral eptfe patch attached to the wire mm sizes available (5 mm increments)

52 ATRIASEPT: Atrial Septal Defect Closure System (Cardia) Double umbrella, 6-arm, woven nitinol frame Retrievable and repositionable Self-centering mechanism No exposed metal on left atrial side of device Total arm length 14 mm larger than centering ring diameter 6 mm - 38 mm 9 Fr 14 Fr sheaths LA view RA view

53 Occlutech Figulla Occluder Tips of the mesh wires brought together in one hub at the right atrial end Reduced material in the left atrium Flat low profile of the left atrial disc No hub or edges on left atrial disc Easy to use and retrievable Sizes: 6 39 mm in 3 mm increments Larger sheath compared with Amplatzer for similar sizes ASD

54 Cera ASD device (Lifetech) Sizes 6 mm to 42 mm (2 mm increments) Need 8 Fr to 14 Fr sheaths Available with a kink-resistant delivery sheath CE mark

55 Devices for PFOs Amplatzer - 18, 25, 30 & 35mm sizes Occlutech - 16/18, 23/25, 27/30 & 31/35mm Helex mm sizes (5 mm increments) Atriasept similar to ASD sizes Premere PFM PFO occluder - 20, 26 & 30mm Coherex Flat stent (13 or 19mm) Helex PFM PFO Coherex Flatstent Occlutech Figulla Premere Atriasept Amplatzer

56 Different Amplatzer VSD Devices Muscular VSD devices Perimembranous VSD devices

57 Self-expandable Nitinol Wire Sizes: 4-18 mm Amplatzer muscular VSD device Device Size (Waist= A) RV Disc = (B) LV Disc = (C) Length of Waist = (D) Waist 16 24mm (2mm increments) Length 10mm Device Size (Waist = A) 4mm 6mm 8mm 10mm 12mm 14mm 16mm 18mm RV Disc (B) 9mm 14mm 16mm 18mm 20mm 22mm 24mm 26mm LV Disc (C) 9mm 14mm 16mm 18mm 20mm 22mm 24mm 26mm Length of Waist = (D) 7mm 7mm 7mm 7mm 7mm 7mm 7mm 7mm

58 Other VSD occluders Nit-Occlud (PFM) Cera VSD occluder (Lifetech) Occlutech VSD occluder (Occlutech)

59 VSD Amplatzer Membranous VSD Waist 4 18mm (1mm increments) Length 1.5mm

60 Nit Occlud VSD coil (PFM) Novel attachment mechanism, 6 Fr delivery catheter Controlled released coil similar to the PDA NitOcclud Stiff distal loops covered with Dacron filaments Distal coil diameter: 10, 12, 14, 18 mm Prox coil diameter: 6, 6, 8, 10 mm Trong-Phi Le

61 Amplatzer duct occluders Self-expandable, mushroom-shaped device made of Nitinol wire mesh Retention disc on one side 2 mm larger than the diameter of the device to ensure secure positioning of the device ADO I sizes from 5/4 16/14 introduced through 6-8 Fr sheaths ADO II - fine nitinol wire mesh shaped into a cylindrical waist with retention discs on either end to secure it in the PDA Available in 4 or 6 mm lengths, waists of 3,4,5, 6 mm (disc 6 mm >waist) ADO II can be introduced through 4-5 Fr sheaths

62 ADO II AS Waist 3-5 mm (discs mm) Length 2, 4 & 6 mm

63 Other PDA Occluders PFM Nit-Occlud - 4 x 4mm 14 x 6mm Cera PDA occluder (Lifetech) 6/4 24/22 mm (2mm increments) Occlutech PDA occluder (developing)

64 Embolisation devices - plugs Vascular plugs (AGA)

65 Plug devices for embolisation Various Amplatzer devices can be used to close fistulas/collaterals ADOs and vascular plugs are useful for some vessels Precise placement but residual flow is common and takes some time to occlude Diameter 4 mm to 16 mm (AVP I), 3 22 mm (AVP II), Diameter 4 8 mm (1mm increments) for AVP IV Stiff delivery cable/sheath may cause difficulties in tortuous routes AVP IV

66 Amplatzer Vascular Plug III Oblong shape, extended rims Controlled delivery and precise placement 4x2 mm to 14x5 mm size, needs 6 9 Fr guide catheter or 4-7 Fr sheath Can be used in arteriovenous fistulas, PAVMs, aortopulmonary collaterals, surgical shunts, venous collaterals and also paravalvar leaks

67 Left atrial appendage closure devices ACP (AGA) - Lobe diameter 16 30mm, disc diameter 20 36mm, lobe length 6.5mm Watchman device - 21, 24, 27, 30 & 33mm

68 Osypka Cerablate wire RF catheters and generators Baylis RF generator and Nykanen wire

69 Embolisation devices - coils Standard coils ( ) Gianturco (various sizes/lengths) Tornado Controlled release coils (0.035 ) Jackson and Flipper coils (Cook) Nit-occlud (PFM) coils Micro coils* ( ) Target GDC/IDC coils (F3 catheter) (Ask interventional radiologists)

70 Coils Made of steel, with Dacron strands, which are thrombogenic One of most versatile and controllable embolization materials Fit through small catheters 3F for microcoils, 5F for standard coils Standard coils Controlled release coils Large stock of sizes and shapes Selection of guiding catheters e.g Tracker-18 catheters to allow coil embolisation of very tortuous vessels

71 PDA coil Coils Standard coils Hilal microcoils

72 Shaped coils Tornado Vortex

73 Inflation devices Become familiar with one type

74 Transseptal needles/catheters Curves BRK, BRK 1 & BRK 2 (paediatric) Lengths 56cm (paediatric), 71, 89 & 98 cm

75 Each individual will have his own preferences

76 Stocking the catheter laboratory Many types of equipment available Choose a limited range and become familiar with them Stock fully if possible Rational stocking of the lab needed, if financial constraints Have the equipment to cover most of the procedures