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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Dr Vipul Gupta