Tricks of handling difficult cannulations Vipul Gupta Neurointerventional Surgery Artemis Agrim Institute of Neurosciences
Tricks of handling difficult cannulations
Vipul GuptaNeurointerventional SurgeryArtemis Agrim Institute of Neurosciences
Cannulations/Access
Aortic arch ICA Distal to aneurysm
Case studies ….
Arch Access
sheath
AB C
Fig. 1 – DSA was done along with 3D angiogram. A broad neck lobulated ICA aneurysm was seen (A). Marked tortuosity of aort and arch vessels was noticed. Arrows in Fig. C outline the course of diagnostic catheter.
sheath
SIM in very tortuous
A B C
D E GF
Arch cannulation
What do I use?Picard (Cook) for most – long sheath Long sheath – Cook, Arrow, Penumbra – be mindful of length
Wire in the ECA, if need be an excahange SIM 2/3 for very tortuous – Amplatz for exchange
Difficult ICA …
Guiding catheter in ICA More important than usually realizedEnvoy 6F – can take double systemsAs high as possible, commonly in petrous ICATerumo 038Prime with NTG, nimodipine
guiding
Guiding in petrous using a 4/5 diagnostic catheter
Distal access catheters …..
Taking Neuron over wire …Always need a long sheath
Co-axially over lower profile DAC
Long sheath Guiding catheter – 6 F co-axial over longer 44
DAC We could go through loops ….
G H
Long sheath Cook Raphe 70 cmDAC - 6 F , 105 cmDAC – 44 , 115 cm Terumo – 35/38
A
B C D
A B
C D
E
Long sheath Cook Raphe 70 cmDAC - 6 F , 105 cmDAC – 44 , 115 cm Terumo – 35/38Prowler 21 ; Traxcess or other MC
If nothing works …Old and best
Different cannulations Distal to aneurysm …
• For balloon .• For stent/FD
Buddy wire ….
Aneurysm cannulations
REVERSE CURVE
Cannulations …
Critical for success ….Different strategies for arch, ICA, intracranial access
Awareness of options and availability of hardware
Long sheaths, distal access catheters and co-axial options have changed the game ….
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