Experience with the Destino Twist Steerable Guiding Sheath with Deflectable Tip

The Destino Twist (Oscor) is a single guiding sheath allowing access to difficult-to-reach vascular anatomy. Cath Lab Digest talks with Dr. Bruno Damascelli and Dr. Vladimira Tichà about their experience with the Destino Twist in procedures such as renal denervation, and its applications for a wide variety of cutting-edge procedures.

Dr. Damascelli, can you tell us about your lab and practice? 

I am an interventional radiologist and I spent my career at National Cancer Institute of Milano.

During my practice, I have explored the field of interventional oncology, particularly in the area of local regional treatments. Recently, experience has been gained using a new chemotherapeutic agent based on paclitaxel charged in human albumin nanoparticles. Successful results have been documented in head and neck cancer, breast cancer, and ovarian cancer, by directly infusing this well-tolerated drug into feeding arteries like the external carotid artery and its branches, mammary artery, and hepatic artery. Also, arteriovenous (AV) malformation embolization has been performed, as well as embolization for bleeding conditions, mostly in the pelvic area. 

Over the last 4 years, along with my colleagues, I have explored the use of renal denervation for the treatment of hypertension and related comorbidities. As experienced by other radiology colleagues and cardiologists, the preferred or obliged access is the femoral artery. The common experience is that it is not always easy to gain and maintain a vascular target in order to accomplish a planned interventional procedure while using available catheterization equipment.

What are some access and procedural challenges that the design of the Destino Twist seeks to overcome? 

The actual outside diameter of the Destino Twist calls for femoral access, but the design and steering features overcome vessel tortuosity when a selective approach is required on both sides of the pelvic area, for example. Selective and super selective catheterization run easier with coaxial technique due to the stable position maintained by the Destino. There is enough room to inject contrast medium that follows, step-by-step, the procedure during fluoroscopy. In other words, the Destino moves the point of the action from initial arterial or venous access to the area of interest, exactly what a good vascular introducer should accomplish. The major advantage can be seen when a stiffer device goes inside the sheath, perhaps balloon catheters or retrieval forceps, or quite recently, intra-arterial radiofrequency electrodes or ultrasound balloon transducers. The practice of embolization even in an emergency situation, in our experience, has been robustly helped by this steering device that also allows telescopic catheterization with new special micro catheters equipped with a funnel, thereby preventing retrograde embolization. Venous sampling in the abdominal area to include hepatic, renal, adrenal, hypogastric vein, and varicocele embolization are other points of interest that have been recently and successfully explored.

Recently, new sheath lengths have been implemented for the Destino Twist, while maintaining the same pre-shaped distal portion. A second port has been added to the handle to add continuous flushing capability or pressure recording. The pre-existing inlet remains free for contrast injection or drugs, just in case. The 90cm length allows for the catheterization of supra-aortic vessel for carotid intervention, stroke units, mammary artery intervention, cardiac valves, and endoleak repair. The other available sheaths are straight and propose a simple deflecting tip, and they also need a larger external diameter than the Destino Twist to achieve its inner diameter of 6.5 French.

Can you describe the Destino Twist steerable guiding sheath with deflectable tip?

Every day, across the wide range of endovascular interventions, we face the question of which material to use in order to overcome anatomical variations, complex pathological situations, age, patient size, vessel size, and so on. These were the reasons for designing a new sheath able to gain the target vessel and maintain position until a final device or devices could complete treatment. The wide variety of French sizes, curve sizes, and length variations give the user many options for gaining access to tortuous anatomy. The Destino Twist differs from the other steerable guiding sheaths because it not only offers the standard straight version, but also has a version with pre-shaped shaft. The proximal curve mimics the Cobra and the distal, the LIMA (left internal mammary artery). This combination is the most suitable for many abdominal vascular accesses. The steering capability just increases the power of engagement of the vessel’s ostium. Maneuvering with the increasing and releasing curves radius allows the device to work properly.

Can you describe its use, step-by-step, in a particular procedure?

A good example for use of the Destino is in endovascular renal denervation, following these steps:

1. Standard femoral artery puncture.
2. 7 French or 8 French standard dilator passage.
3. Insertion of Destino Twist with its dilator.
4. Destino distal tip arrives at T12 level and dilator is removed, with the standard guide wire having the tip still inside the edge.
5. Sheath is flushed and rotating the cursor, the curve is achieved.
6. Contrast medium injection allows viewing of the origin of the renal artery.
7. Sheath is gently pulled down until the vessel is engaged and angiography is performed.
8. Once we have the vessel sizes, the electrode is advanced inside the sheath and with the use of fluoroscopy, slipped inside the artery.
9. The action with the cursor increases or releases the curve of the sheath, avoiding dislodgement from the artery.
10. The procedure is repeated on the other side. At the end, the sheath is removed and an arterial closure device applied.

Are there any advantages for hemostasis?

There are no particular advantages. Standard closure devices can be used.

Do you have any tips or tricks for use?

Yes, previous passage of a dilator is mandatory and heparinized saline is mandatory.

How would you describe the learning curve? 

The learning curve is very short. Because of its intuitive design, doctors can learn to use the Destino Twist immediately. 

Does use of the Destino Twist save time? 

Definitely, the Destino Twist saves material, time, and amount of contrast medium injected. Having a steerable sheath also minimizes the need for many different fixed sheath curve configurations in the hospital’s inventory.

Do you have any advice for interventionalists who may have a need for this type of sheath?

We only recommend trying it. They surely will be able to discover other fields of use such as venous, biliary, or urological intervention, and many more.

What do you envision as the future of the Destino Sheath?

If the technology evolves, there will be more different external/internal diameters, lengths, and curves available, so this sheath will get more use for all types of simple and complex interventions.