Easiest way for the arterial puncture is good localization with gentle palpation. If you fail to puncture the artery then before withdrawing the needle palpate the artery to know if needle is medial or lateral to the artery.

Never push the guide wire or the catheter with force or against resistance.

Prepare the catheter(sucking blood, flushing and filling with contrast) in the root of aorta rather than in coronary artery as far as possible.

Must have a decent pressure waveform before you inject anything.

Loss of the pressure usually means that the catheter may be developing a knot.

To cancel a knot rotate the catheter in reverse direction while gently advancing a wire in it.

First injection should be always very gentle and small in amount and be sure that contrast is cleared away.

Aorta to LV- with a pig-tail catheter make a curve at the aortic valve in PA view, now gently advance the wire in it.

First view in coronary angiography should be a shallow RAO(5-10*RAO) to define the left main coronary artery.

If entering the pulmonary artery is difficult, position the catheter at the RV apex then slowly withdraw it while giving it a anticlockwise rotation and it will tend to go to RV outflow.

In a patient with coarctation of aorta when using femoral access, use a soft wire(turmo or wholly) as it will not pierce a collateral.

To enter the subclavian or innominate artery place the right judkins in the aortic arch and rotate it anticlockwise, moving catheter up and down in descending aorta is not useful.

If a diagnostic catheter is difficult to totate then rotate it with guide wire in it.

In a patient with dissection of aorta, avoid diagnostic aortogram. If you have to do it use a french 8 size pig tail as it can deliver more contrast and one injection itself will be very useful.

If a secondary curve is desired then hair dryer is also as useful as warm saline.

If a new PTCA balloon is taken from the shelf and prepared with suction with syringe only, without any contrast, then it will become a low profile balloon. Advantage is that if it did not cross the lesion then it will be easy to wash and still be kept as a new balloon.

If GTN infusion is kept continuously running please keep rotating the bottle as it tends to settle at the bottom.

In unstable angina/acute MI only one vessel PTCA should be done in one sitting.

If vessel is tortuous using an extra-support wire will straighten it.

If in a LAD system the guide wire is going in diagonals or septals go to the left lateral view and keep the tip looking upwards as septals and diagonals will have downward direction opening or alternatively go to PA-caudal view and aim downward movement.

Keep the extra length of the hardware assembly with a “U” curve on the table so that any extra movement by hand does not bring the entire assembly backwards as it will pull the guide-wire out of the artery.

In choosing a guiding catheter if you compare with the diagnostic judkins, PTCA guide should be 0.5 size smaller. Note that if guide is giving problem then for LAD choose 0.5 size smaller and for Circumflex choose 0.5 size larger or change to an amplatz/voda.

A seven or six French catheter is more user friendly.

If during PTCA a flap has developed especially in the proximal segment of the artery, then diagnostic injections should be gentle as it can further lift the flap.

While using Simpson’s atherocarh(DCA)

• Always inflate the balloon before advancing or withdrawing the cutter.
• After cutting withdraw cutter 1 or 2 mm and push it in nose cone so that the material is well pushed in the nose-cone and will not come back in the lumen of the coronary artery.

While using rotational coronary ablator(ROTABLATOR)

• Always have wire rotator(preferably two) fixed on the wire before spinning, otherwise during high speed rotation the wire tip will be embedded in vessel wall.
• If the wire tip is embedded in the vessel wall, then do not pull the wire with a force as part of the wire proximal to the distal end is very sharp. It can dissect a major vessel or even the left-main. Advance a balloon upto the distal end of the wire and then pull the guide-wire. Sometimes it may break and if patient is going for surgery to remove the wire then ask the surgeon to open the vessel near the distal end and pull the wire from the distal end.
• Never allow angulation to develop in the wire during the procedure as the wire will break here.
• If you suspect that the wire has broken then withdraw the whole assembly out, this way the distal end is likely to come out.

• Inflate quickly at 11- 18 atmosphere. Be careful as you may also inject air
• Deflate the balloon with a 50 ml syringe.
• Balloon rupture usually occurs after crimping. Some operators will suck to make sure there is    no rupture and then leave balloon at 0 atmosphere.

• Initially predilate with a smaller size balloon
• Deploy the stent(preferably self expanding or a mounted one where the ballon tapers at the edges) and dilate the stent to an optimal size.
• Avoid high pressure dilatations outside the stent margins.

• Try the brachial access.
• Canulate the IMA with the RCA catheter, if difficult then canulate with the IMA catheter and change with a RCA catheter.

• Regain the J cure
• Will tend to go to natural branches
• Will torque easily
• If not sure that you are in true lumen initially dilate with a small size balloon

• If the lesion is above the bifurcation pass an extra stiff wire in external carotid to bring in the guiding catheter.
• If the stent has come off the ballon it can be retrieved by advancing a coronary balloon in it.