“shepherd” technique for stent deployment · 2017. 6. 16. · •intermediate catheter (+/-...
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“SHEPHERD” TECHNIQUE FOR STENT DEPLOYMENT
JASON WENDEROTH
PRINCE OF WALES AND LIVERPOOL HOSPITALS
SYDNEY
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TWO MAJOR CHALLENGES IN STENT DEPLOYMENT
• Stent torsion
• Stent prolapse into aneurysm
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THE TORSION PROBLEM
• Tortuous anatomy
• ”Round-the-world” access
• Long stents
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THE TORSION PROBLEM
• Torque on catheters transmitted to FDS
• Mid/proximal stent twists
• Non-opening
• Angioplasty-resistant
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THE PROLAPSE PROBLEM
• Broad-necked/giant aneurysms
• Aneurysms occupying >50% circumference of vessel
• Insufficient proximal, distal or lateral support during “push” phase of stent deployment
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FDS TORSION PROBLEM
• Alternate unsheathing of stent delivery catheter and stent
• Intermediate catheter (+/- buddy wire) provides support for delivery catheter and stent
• Intermediate catheter can be used to “nudge” proximal end of stent for optimal opening
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65M ex-smoker
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FIRST PROCEDURE
• Aneurysm crossed “round the world”, microcatheter in M2
• Intermediate catheter proximal to aneurysm
• Failed FDS deployment:
• PED 4.75 x 30mm
• PED 4.5 x 30mm
• FRED 4.5 x 26mm
• Acute stroke presented – procedure abandoned; rebooked
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THE ”SHEPHERD” TECHNIQUE
• Initial access beyond aneurysm via microcatheter
• Direct or “round the world”
• Standard or balloon microcatheter
• Torque accrues on primary access catheter
• Intermediate catheter advanced distally over primary catheter
• Stent delivery catheter (no torque) via intermediate catheter +/- buddy wire alongside if concerned re stent prolapse
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Intermediate catheter
• Distal balloon access
• Inflate balloon for stability
• Torque stored in loop
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• Tension on balloon catheter to remove loop
• Torque transmitted to balloon shaft
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• Balloon shaft straight, tension stored
• Use balloon shaft as rail
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• Advance intermediate catheter over balloon shaft
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• Place intermediate catheter well distal to aneurysm
• Can tension balloon shaft to cross aneurysm “lip”
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• Final position of intermediate catheter
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• Deflate balloon and remove
• May leave “buddy” wire in position if very difficult/tortuous access
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Buddy wire
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• Remove balloon
• Prepare stent-delivery catheter
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• Advance stent delivery catheter as distally as is safe
• Maintain intermediate catheter position +/-buddy wire
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• Commence unsheathing of stent lead wire
• Maintain intermediate catheter position
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• Withdraw intermediate catheter
• Expose stent delivery catheter in preparation for stent delivery
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• Gradual retraction of delivery catheter until stent opens distally and apposes wall
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• Slow unsheathing of delivery catheter to permit unsheathing of next stent segment
• Buddy wire can be very helpful here…
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• Next segment of stent delivered
• Manipulation by freely-moving delivery catheter with intermediate catheter support
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• Gradual retraction of delivery catheter and intermediate catheter until stent opens distally and apposes wall
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• Next segment of stent delivered
• Manipulation by freely-moving delivery catheter with intermediate catheter support
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65M ex-smoker
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65M ex-smoker
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65M ex-smoker
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SUMMARY
• You’re probably doing this already
• If not, try it – it works!
• We find it useful with difficult anatomy to get our stents open
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