Difficult Anatomies: Use Three Hands

Today’s interventional cardiologist is armed with a vast array of devices for treatment of increasingly difficult lesions. Inhospitable anatomies previously considered suitable only for surgical therapy are now frequently accessible with modern tools and techniques. Extra back-up guiding catheters as well as extra-support guidewires provide solid platforms for device delivery. “Buddy wires” help to deflect stents from vessel wall calcifications while the Wiggle Wire (Guidant Corp., Indianapolis, Indiana) actually allows the stent to bounce away from potential obstacles. Alternatively, the Rotaglide (Boston Scientific Corp., Natick, Massachusetts) lubricant has been applied directly to the undeployed stent surface to successfully overcome vessel resistance.¹

Nonetheless, at times, a simple maneuver can provide just enough “push” to accomplish device delivery. For example, deep inspiration causes caudal displacement of the diaphragm as well as the heart. This action can potentially ameliorate an acute vessel segment angulation. The relative negative intrathoracic pressure thus generated may also aid in drawing the device centrally.²

During routine device delivery, most operators advance over-the-wire devices with the right hand, while holding the Touhy connector with the left. The guidewire is stabilized by the scrubbing assistant. When using rapid exchange systems, the Touhy connector may be held with the left middle and ring fingers while the device is advanced with the thumb and index finger. The wire is affixed with the operator’s right hand in this case. If device transit results in guiding catheter disengagement, the catheter is repositioned over the taut wire/device system, and the attempt is repeated. However, subsequent device delivery frequently produces identical catheter “back-out”, as there is no concurrent counteracting forward force to maintain catheter engagement.

We have found, however, that simultaneous forward force on the guiding catheter during device advancement, with concomitant stabilization of the Touhy connector greatly enhances delivery success. In this case, the operator’s left hand maintains constant forward pressure on the guiding catheter shaft just proximal to the access sheath. The right thumb and index finger are used to advance the device, while the middle and ring fingers grasp the side-port of the Touhy connector, exerting gentle opposing (backward) force to enhance device delivery. This simultaneous push-pull action allows for more focused control of advancement.

The scrubbing assistant holds the guidewire close to the exit site and maintains firm wire position (Figure 1).

This method is applicable to both over-the-wire and rapid exchange platforms. In cases where traditional equipment delivery techniques result in guiding catheter extrusion or “back-out”, we have frequently experienced success using this simple maneuver, obviating the need for a second wire or equipment change. For more challenging anatomies, this technique can of course be employed in conjunction with other means of device transit facilitation.

References

1. Chan AW, Ramee SR, Collins T, et al. Rotaglide-facilitated stent delivery: Mission accomplished. Catheter Cardiovasc Interv 2003;59:477–481.

2. Chen JP. Difficult anatomies — Just hold your (patient’s) breath. J Invasive Cardiol 2006;18:642.