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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3585_Библиотеки_им_академика_М_И_Перельмана
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a
b
c
d
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However, this can only be done when the guidewire has
a soft tip. If this method fails to stop the exit port encountering the vessel wall, there are two other techniques to try.
The rst technique (used conventionally) is to remove the
imaging core of the IVUS catheter and to introduce a guidewire with a stiff tip into its shaft. The stiff tip of the guidewire will straighten the IVUS catheter around its exit port
and direct the catheter toward the larger curvature of a bend.
This may shift the exit port away from the obstruction and
facilitate withdrawal of the catheter (Fig.5.46c). The second
technique is to advance a balloon along the guidewire of the
IVUS catheter as far as the exit port and thus create another
gap to offset the gap at the exit port that is preventing smooth
withdrawal of the catheter (Fig.5.46d).
If the shaft of the IVUS catheter needs to be disassembled
for removal of the imaging core, the second technique using
a balloon is the only option. To permit delivery of a balloon
catheter together with an IVUS catheter, a 7-Fr or larger
guiding catheter is needed. This is one reason why I choose
a 7-Fr guiding catheter for PCI of a bifurcation lesion, CTO,
or severely calcied lesion.
5 Mitsudo’s Non-pushing PCI Techniques
a
Fig. 5.46 Trapping of an IVUS catheter during withdrawal. (a) An
IVUS catheter has a gap at its exit port, which may catch on a stent strut
b
Fig. 5.45 Trapping of devices during advancement or withdrawal.
During advancement, a device may be caught by irregularities on the
larger curvature of a bend (a). During withdrawal, a device may be
caught by irregularities on the smaller curvature of a bend (b)
during withdrawal of the catheter. Forcible attempts to withdraw the
catheter after it has become caught on a stent strut may lead to deformation of the stent. (b) Advancing a guidewire into the IVUS catheter may
direct the catheter toward the larger curvature at a bend. (c) Sliding the
imaging core back slightly and then advancing a guidewire into the
IVUS catheter may straighten the catheter around the exit port and
facilitate withdrawal. (d) Advancing a balloon along the guidewire to
the exit port creates a large reverse gap, which will offset the gap at the
exit port and facilitate withdrawal of the catheter
5.10 Removing anIVUS Catheter
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273
5.10.2 If theIVUS Catheter Is Caught,
ButNot Stuck
There might be little difculty withdrawing an IVUS catheter through an implanted six-link stent (Cypher) or threelink stent (Xience).
However, you must pay attention if a device is even
slightly caught by the strut of a two-link stent, because this
may induce subtle stent deformation that cannot be identied by CAG and leads to subsequent in-stent thrombosis
or restenosis. Of course, such stent deformation will not be
found by IVUS if it occurs during withdrawal of the IVUS
catheter. On the basis of favorable IVUS ndings, many
interventionalists might mistakenly regard such deformation as being unrelated to PCI.An IVUS catheter should be
withdrawn slowly. If the catheter is even caught slightly during withdrawal, you should stop withdrawing it and use the
abovementioned techniques to offset the gap before attempting to withdraw it again (Fig.5.47).
Fig. 5.47 IVUS after stenting of a LAD bifurcation lesion. The IVUS catheter was caught on the stent during withdrawal, causing stent deforma-
tion (arrow).
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