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Contents
Basic Tools Required to Perform Angioplasty and Stenting Procedures .1
David O. Kessel
Arterial Pressure Measurements ...................... 13
Thomas B. Kinney
Drugs − Pre-, Peri- and Post-intervention ................. 17
Raman Uberoi
Arterial Access ................................ 27
Dimitrios K. Tsetis
Venous Access ................................ 41
Clare L. Bent and Matthew Matson
General Principles of Angioplasty and Stenting .............. 57
Elias N. Brountzos and Efthymia Alexopoulou
Arterial Closure Devices ........................... 73
Stephen P. D’Souza and Dare M. Seriki
Aortoiliac Angioplasty and Stenting .................... 85
Robert A. Hieb
Angioplasty and Stenting of the Superficial Femoral Artery and
Popliteal Artery ............................... 97
Anna-Maria Belli
Subintimal Angioplasty ........................... 111
Guy Fishwick
Infrapopliteal Angioplasty and Stenting .................. 129
Marc Sapoval, Olivier Pellerin, and Laurent Bellmann
Renal Artery Angioplasty and Stenting .................. 141
Sanjay Misra
Angioplasty/Stenting of Mesenteric Arteries ................ 153
Stefan Müller-Hülsbeck
xi
xii Contents
Carotid Stenting and Angioplasty ..................... 167
Gerald Wyse and Kieran J. Murphy
Intracranial and Vertebral Artery Angioplasty and Stenting ...... 187
Jitendra Sharma, J. Mocco, Adnan H. Siddiqui and Elad I. Levy
Angioplasty/Stenting of the Subclavian and Axillary Arteries ...... 195
Trevor John Cleveland
Stent-Grafting of the Thoracic Aorta ................... 207
Jean-Paul Beregi and Marco Midulla
Elective Endovascular Aneurysm Repair (EVAR) of Abdominal
Aortic Aneurysms (AAA) .......................... 225
Johannes Lammer and Maria Schoder
Endovascular Management of Ruptured Abdominal Aortic Aneurysm . 239
William C. Loan and Chee Voon Soong
Angioplasty/Stenting/Lysis/Thrombectomy of Hemodialysis Access ... 251
Himanshu Shah and Gordon McLennan
Thrombolysis for Acute Lower Limb Ischemia .............. 275
Thomas O. McNamara and Susie J. Muir
Endovascular Treatment of Acute Stroke ................. 291
Ali R. Zomorodi and Tony P. Smith
Venoplasty and Stenting ........................... 303
Haraldur Bjarnason
Venous Thrombolysis and Thrombectomy for Deep Venous Thrombosis 317
Nael E. A. Saad and Suresh Vedantham
TIPS (Transjugular Intrahepatic Portosystemic Shunts) ........ 327
George Behrens and Hector Ferral
Index ..................................... 337
Contributors
Efthymia Alexopoulou Second Department of Radiology, Attikon University
Hospital, University of Athens, Medical School, Chaidari, Athens, Greece
George Behrens Department of Radiology, Rush University Medical Center,
Chicago, IL, USA
Anna-Maria Belli Department of Radiology, St George’s Hospital, London, UK
Laurent Bellmann Cardiovascular Radiology, Hospital Européen Georges,
Pompidou, Paris, France
Clare L. Bent Department of Interventional Radiology, University Health
Network – Toronto General Hospital, Toronto, ON, Canada
Jean-Paul Beregi Department of Cardiovascular Imaging and Intervention,
Hôpital Cardiologique – University Hospital of Lille, Lille, France
Haraldur Bjarnason Division of Vascular and Interventional Radiology, Mayo
Clinic, Rochester, MN, USA
Elias N. Brountzos Second Department of Radiology, Attikon University
Hospital, University of Athens, Medical School, Chaidari, Athens, Greece
Trevor John Cleveland Sheffield Vascular Institute, Sheffield Teaching Hospitals
NHSFT, Sheffield, UK
Stephen P. D’Souza Department of Interventional Radiology, Lancashire
Teaching Hospitals NHS Foundation Trust, Preston, UK
Hector Ferral Department of Radiology, Rush University Medical Center,
Chicago, IL, USA
Guy Fishwick X-Ray Department, University Hospitals Leicester, Leicester
Royal Infirmary, Leicester, UK
Robert A. Hieb Department of Vascular and Interventional Radiology, Medical
College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, WI,
USA
xiii
xiv Contributors
David O. Kessel Department of Radiology, Leeds Teaching Hospitals, Leeds, UK
Thomas B. Kinney Department of Interventional Radiology, UCSD Medical
Center, San Diego, CA, USA
Johannes Lammer Department of Cardiovascular and interventional Radiology,
University Hospital Vienna, Vienna, Austria
Elad I. Levy Department of Neurosurgery, University at Buffalo, Buffalo,
New York, USA
William C. Loan Department of Radiology, Belfast MSC Trust – City Hospital
Site,Belfast,UK
Matthew Matson Imaging Department, Barts and the London NHS Trust,
London, UK
Gordon McLennan Department of Radiology and Bioengineering, Cleveland
Clinic, Cleveland, OH, USA
Thomas O. McNamara UCLA School of Medicine, David Geffen School of
Medicine, University of California Los Angeles, Los Angeles, CA, USA
Marco Midulla Department of Cardiovascular Imaging and Intervention, Hôpital
Cardiologique – University Hospital of Lille, Lille, France
Sanjay Misra Department of Radiology, Mayo Clinic, Rochester, MN, USA
J. Mocco Departments of Neurosurgery and Toshiba Stroke Research Center,
University at Buffalo, Buffalo, New York, USA
Susie J. Muir Department of Radiological Sciences, University of California Los
Angeles, Los Angeles, CA, USA
Stefan Müller-Hülsbeck Diagnostic and Interventional Radiology/
Neuroradiology, Academic Hospitals Flensburg – DIAKO, Flensburg, Germany
Kieran J. Murphy Department of Medical Imaging, University of Toronto,
Toronto, ON, Canada
Olivier Pellerin Cardiovascular Radiology, Hospital Européen Georges
Pompidou, Paris, France
Nael E.A. Saad Department of Interventional Radiology, Washington University
School of Medicine, St. Louis, MO, USA
Marc Sapoval Cardiovascular Radiology, Hospital Européen Georges Pompidou,
Paris, France
Maria Schoder Department of Cardiovascular and Interventional Radiology,
Medical University of Vienna/AKH, Vienna, Austria
Dare M. Seriki Department of Radiology, Lancashire Teaching Hospitals NHS
Foundation Trust, Preston, UK
Contributors xv
Himanshu Shah Department of Interventional Radiology, Indiana University
School of Medicine, Indianapolis, IN, USA
Jitendra Sharma Buffalo Neuroimaging Analysis Center and the Jacobs
Neurologic Institute, University at Buffalo, Buffalo, New York, USA
Adnan H. Siddiqui Department of Neurosurgery, University at Buffalo
Neurosurgery, Buffalo, New York, USA
Tony P. Smith Department of Radiology, Duke University Medical Center,
Durham, North Carolina, USA
Chee Voon Soong Vascular and Endovascular Unit, Belfast Health and Social
Care Trust, Belfast, UK
Dimitrios K. Tsetis Department of Radiology, Unit of Angiography and
Interventional Radiology, University Hospital of Heraklion, Heraklion, Crete,
Greece
Raman Uberoi Department of Radiology, John Radcliffe Hospital, Oxford, UK
Suresh Vedantham Department of Interventional Radiology, Washington
University School of Medicine, St. Louis, MO, USA
Gerald Wyse Interventional Radiology, The Johns Hopkins Hospital, Baltimore,
Maryland, USA
Ali R. Zomorodi Department of Surgery and Neurosurgery, Duke University
Medical Center, Durham, North Carolina, USA
Basic Tools Required to Perform Angioplasty
and Stenting Procedures
David O. Kessel
Introduction
This chapter deals with selection of basic tools needed to perform angioplasty and
stenting procedures. The key to success in angioplasty and stenting as in most
interventional procedures is preparation.
Before starting you should ensure that you have
• A clear understanding of the indications and contraindications for the procedure.
• Reviewed the preprocedure imaging to assess lesion location, morphology, and
length.
• A plan of campaign, a backup plan, and an exit strategy.
• Considered the likely approach to be used.
Other chapters will detail the requirements in specific cases. Here, we will reflect
on the basic principles, which in conjunction with your knowledge and experience,
will allow you to select the correct catheters, guidewires, sheaths, guide catheters,
balloons, and stents to treat the patient and to manage any emergent problems.
The equipment below (Table 1) can be considered as essential tools for the
following steps:
Each type of equipment will be considered in turn. Procedural techniques,
contrast, and injection pumps will not be discussed.
Ta bl e 1 Essentials tools
Stage Equipment
Vascular access Sheaths and guide catheters
Crossing the lesion Catheters and guidewires
Angiography Catheters, contrast, and injector
Treating the lesion Angioplasty balloons and stents
Managing complications Mainly stents and stent grafts
Puncture site Closure device; not routinely indicated
1
R.A. Morgan, E. Walser (eds.), Handbook of Angioplasty and Stenting Procedures,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-399-6_1,
C
Springer-Verlag London Limited 2010
2 D.O. Kessel
Sheaths and Guide Catheters
A vascular sheath is advisable for all but the simplest angiographic procedure,
especially if there will be catheter and wire exchanges.
A guide catheter is simply a catheter with a large lumen. This allows other
catheters and devices to be deployed through it and “guided” to their target.
There are three principal differences between a long sheath and a guide catheter:
• Sizing: Remember that for a vascular sheath, the French size refers to the circum-
ference of the inner lumen as opposed to a catheter, where the French size is the
outer circumference. In other words, a 6F sheath will accommodate a 6F catheter
but not vice versa.
• A long sheath comes with an introducer, allowing direct placement into a ves-
sel. A guide catheter does not have an introducer and so is inserted through an
appropriately sized sheath.
• A sheath has a hemostatic valve, which will accommodate devices up to the
French size of the sheath. To prevent bleeding around the guidewire, a guide
catheter needs to be fitted either with a removable hemostatic valve or a Tuohy-
Borst adapter. In either case make sure that any device you plan to insert will pass
through the catheter and valve!
The most important factors when deciding what to use are
• What is the largest device that will be needed during the procedure?
This determines the size of the sheath.
b
The simplest strategy is to start with a sheath that will accommodate the largest
device that you are likely to require. This means that you will not need to spend
time making sheath exchanges while you are in a precarious position. The
disadvantage of this strategy is that you will be left with the biggest puncture
site hole, even if you are unsuccessful.
b
Alternatively, if there is a significant chance that the procedure will not be
technically possible, consider starting with a smaller sheath until you have
traversed the lesion. At this point a larger sheath can be inserted which can
accommodate the device to be used, taking care not to lose access across the
lesion.
• Will additional stability be helpful?
b
If so, consider using a long sheath or guide catheter, which can be positioned
close to the target lesion.
b
This effectively shortens the working distance from the operator, e.g., when
working with monorail systems over 0.014" guidewires.
• How far is it to the target lesion?
b
This determines the length of the sheath/guide catheter.
Basic Tools Required to Perform Angioplasty and Stenting Procedures 3
b
If the sheath is purely to allow vascular access and catheter exchange, a
conventional short sheath will suffice.
b
When the sheath is also used to provide support to the working catheter and
guidewire, it must be long enough to reach from the point of access to the
target lesion.
b
It is self-evident that your catheters and guidewires must be long enough
to pass through the sheath/guide catheter. While it is obvious that a 65 cm
catheter will be too short in a 90 cm sheath, it is less evident that the lengths
on the packaging can be misleading. For example, some 100 cm catheters will
barely reach the tip of a 90 cm guide catheter.
b
The time to experiment with this is before starting the case! If there is any
doubt, check the lengths before starting the case.
• What shape to use?
b
Guide catheters can be obtained in a variety of shapes.
b
Some long sheaths have an angled tip like a multipurpose catheter. The shape
allows a combination of steering as well as support.
b
Choose the optimal shape as you would any catheter by assessing the angle of
the target vessel from its parent artery.
b
In general, simple shapes are easier to use and are usually just as effective.
Angiographic Catheters
Catheters are needed for two tasks:
• Diagnostic angiography:
b
In many cases, the anatomy will have been defined by the preprocedural imag-
ing. If there are unanswered questions, formal angiography will be required.
This is best performed with a catheter with multiple side holes.
b
When choosing the catheter consider the flow rate necessary and bear in mind
that the catheter lumen diameter and length will affect this so that a 4F pigtail
catheter suitable for a distal aortic run might not give sufficient flow for an
arch aortogram.
• Traversing the lesion:
A catheter and a guidewire combination is used to traverse a lesion. The tech-
niques for doing this are discussed in subsequent chapters. Simple principles and
personal preferences should influence selection. Follow these basic rules:
1. Select a catheter that points in the general direction you wish to travel. For
example, if you want to cross the aortic bifurcation, you need at least the
curvature of a cobra catheter but may find it easier with a renal double curve
4 D.O. Kessel
catheter or even a true reverse facing catheter such as a shepherd’s hook
shape (Sidewinder/Simmons/Sos).
2. Select a catheter that affords enough torque and trackability. The catheter
performance will be affected by its size and construction. Stiffer catheters
have greater torque control, but tend to be more reluctant to track around
curves. In general, a mid-range catheter is the best option. Hydrophilic
catheters offer little support. Highly braided catheters, while having excel-
lent torque control, tend to be rather “all or nothing” in their response.
3. Select the smallest suitable catheter that will do the job effectively. In prac-
tice, there is little that cannot be managed with the appropriate modern 4F
catheter.
4. Select a long enough catheter to reach your target, taking into account any
sheath or guide catheter.
5. Use a catheter that fits snugly on the guidewire. Trying to advance a catheter
with a 0.038" lumen over a 0.035" or 0.018" wire may lead to frustration,
as the catheter will tend to snag on any stenosis it encounters.
6. Keep it simple. Choose the access point and the catheter, which maximizes
the chance of succeeding. This is usually the most obvious straightforward
route.
Guidewires
Think of wires in terms of steerability, tip length, support, and coating.
• Steerability: Just about any wire can be pointed in the correct direction using a
catheter, but not all wires allow additional steering. For example, neither J-wires
nor straight-tip wires are steerable. To be steered, a wire must have an angled
tip and sufficient torquability to allow rotation of the shaft to transmit to the
wire tip.
• Tip length: All guidewires have a variable length flexible tip. This is usually
2–4 cm long. Wires designed for use where there is limited access will have
1 cm flexible tips. Other wires have very long flexible tips and are intended to be
very atraumatic; the corollary of this is that the wire will only be stable when it
is deeply engaged in the target vessel.
• Support: The support afforded by a guidewire varies considerably and depends
on the wire diameter and its construction. The commonest guidewire sizes are
0.035", 0.018", and 0.014", but other sizes such as 0.038" and 0.021" wires also
exist. In general, thinner wires are less supportive than their thicker counter-
parts. It is essential to use a wire, which will pass through your catheter (see the
Table 2 below).
Basic Tools Required to Perform Angioplasty and Stenting Procedures 5
Ta bl e 2 Catheter and wire compatibility
Device Typical guidewire Comments
Conventional 4F catheter 0.035" Some take 0.038" wire or microcatheter
3F catheter, low profile
over the wire
angioplasty balloon
0.018" Some 0.018" wires are surprisingly
supportive
Microcatheter or
low-profile monorail
balloon/stent
0.014" Will need guiding catheter or long sheath
The construction of the wire will markedly affect how supportive it is. You can
gauge this by seeing what length of wire can be held out horizontally. Very stiff
wires are intended to be used for support and not for negotiating through a vessel.
To advance a stiff wire into place, a catheter must first be guided to the site using
a conventional wire. The wire is subsequently exchanged for the stiff wire. Take
care while doing this, as the stiff wire will have a propensity to dislodge the
catheter.
• Coating: Hydrophilic wires have a coating, which is designed to be slippery when
it is wet. Never pass a hydrophilic wire through a puncture needle as the coating
may be stripped off and may embolize into the distal circulation. A pin vice is
indispensable for gripping and turning a hydrophilic wire. As hydrophilic wires
dry, they tend to become sticky and can readily stick to the operator’s gloves or a
gauze swab. This is a common cause for losing position.
Selecting the right wire: Once again it is a case of each to his own, but these simple
considerations may help you choose:
1. Several different wires may be needed during the course of a procedure.
2. Steerable hydrophilic wires are excellent for manipulating across stenoses and
into branch vessels. They are mandatory for subintimal angioplasty.
3. Straight-tipped wires in conjunction with a steerable catheter are helpful for
gently probing occlusions to try to identify the true lumen.
4. Supportive wires are extremely useful once a position has been obtained.
5. Regarding guidewire length, make sure that the guidewire is long enough to
reach the target and to enable catheter exchanges. This sounds trivial and obvi-
ous, but is a guaranteed source of frustration and is a potential complication if
it is not taken into account. Remember the following formula to allow catheter
exchange:
Guidewire length ≥ total length in the body + length outside the
body in the sheath or guide catheter + length of any
over the wire catheter to be used.