Cath Lab Digest - September 2007 - (Page 29)

29 for the vast majority of right coronary interventions. Note that different Hockey Stick shapes are provided which often differ by manufacturer. Interestingly, guiding catheter support from the right upper extremity approach is generally superior to that found by the femoral approach. For left coronary interventions, the size of the aortic root and the take-off of the left main coronary determine the appropriate shape guiding catheter. Common considerations include EBU-3.5, EBU4.0, XB-3.5, XB-4.0, KIMNY, AL-1.5, and AL-2 shapes. I would recommend performing all catheter exchanges over a wire. This maintains access to the central vasculature in the event of spasm and likely reduces the potential for vascular injury (dissection, embolization, etc.). Glidesheath (Terumo Co., Tokyo Japan), which provides all of these features. Although I use a short (10cm) length sheath, some operators feel that a longer sheath (21–25 cm) extending to the brachial artery helps facilitate catheter manipulation. If there is any resistance, sheath advancement must be immediately stopped. An arteriogram with half strength contrast is often helpful at this point in order to define the cause of obstruction. If the sheath is not in the lumen, the transradial approach must be abandoned. Otherwise, tortuousity and spasm can usually be overcome with the selection of a torquable/hydrophilic wire or anti-spasm medications. With the sheath in place, consideration regarding medications must be given. I routinely administer 0.2 µg of nitroglycerin through the side arm of the sheath in order to prevent proximal arterial spasm. Many operators also administer a calcium channel blocker such as diltiazem 500µg or verapamil 250–500µg. Heparin is also an important medication. As post-procedure patency of the radial artery correlates with level of anticoagulation, I routinely administer 5000u for diagnostic cases. I always administer the heparin within the central circulation though the catheter (aortic root) as it is an acidic medication and patients frequently complain of a burning pain when it is administered through the sheath. It is also important to consider analgesics and anxiolytics. In our lab, midazolam and sublimaze are routinely administered unless there is a contraindication. This makes the procedure more comfortable for the patient — and therefore often makes it a more comfortable case for the physician! Advancement of the catheter over an 0.035-0.038” guidewire is encouraged in order to facilitate crossing of the inominate artery and its branches. Tortuous, calcified subclavian/inominate arteries are sometimes encountered, especially in elderly and hypertensive patients. Use of a shapeable and steerable wire along with a deep breath hold by the patient can help catheter navigation. I usually use a 0.035” flexible J tip wire with a moveable core (Emerald, Cordis Corporation, Miami, FL) which allows adjustment of the stiffness at the end of the wire. The choice of optimal catheters from the right radial approach is important. Compared to angiography from the femoral approach, right Judkins and pigtail catheters can be sufficient, but the left Judkins is often suboptimal. An AL-2 or Castillo-2 (Cordis) catheter is often a good choice for angiography of the left coronaries. There are also specialty catheters which allow for angiography of both left and right coronaries, such as Kimny (Boston Scientific, Maple Grove, MN) or Sones. A multi-purpose or Sones catheter can also be used for ventriculography. As an aside, I would recommend performing all catheter exchanges over a wire. This maintains access to the central vasculature in the event of spasm and likely reduces the potential for vascular injury (dissection, embolization, etc.). There are some unique features to performing coronary interventions from the radial approach. Due to the differences in working space, I will often have a Mayo stand or similar small table covered with a sterile drape and placed between the armboard and the table. While not necessary, the working space makes it preferable to use short wires and rapid exchange platforms. In regard to guiding catheters, I use only 6 French sizes and have found that AL0.75 and Hockey Stick guiding catheters provide excellent support Post Procedure Care Following the procedure, the sheath is removed and pressure is applied over the radial artery for total of 1 to 1.5 hours. Pressure should be occlusive for the first 10–15 minutes and gradually released over the remaining duration. Different methods are utilized for the continuous application of pressure. A firmly-rolled gauze “bullet” can be applied under a HemoBand (HemoBand Corp., Portland, OR), or specially-designed devices can also be utilized. The newest is the TRI band (Terumo), which consists of clear polymer bracelet with an inflatable bladder positioned over the puncture site (Figure 2). This device is comfortable for the patient and has the advantage of allowing continuous observation of the puncture site. Once the pressure device is removed, we apply a folded 4x4 gauze over the site and secure it with elastic tape. The patient removes this dressing the following day and applies a BandAid. Instructions are given to avoid lifting anything heavier than 5 lbs. for 3–4 days. The transradial approach to cardiac catheterization has achieved significant popularity in many countries outside of the United States and has been a significant benefit to the patients served by our cardiac catheterization laboratory. With increasing physician and patient awareness and the potential for increased availability for industry-sponsored educational and training opportunities (Terumo, Cordis, and Boston Scientific all offer programs), the popularity of this technique within the U.S. may see similar growth. Dr. Caputo can be contacted at caputo331@msn.com Navigation of the Catheter to the Aortic Root and Proper Catheter Positioning Once the arterial sheath is in place, catheters are advanced into the aortic root.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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