Diagnostics Cases
PTCA And Intervention Cases
Basic Tips (PTCA And Intervention)
Pacemaker Tips And Cases
Legal Disputes
Radiation Cardiology
An Important Lesson
Your Pages
Basics Tips

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.

Before taking stent make sure that lesion site is dilated in more than one view.

Be sure of stent placement before inflating it.

When LAD ostium is being tackled with the stent then remember that the assembly will also come in the left-main.

After deploying the stent, push the balloon slightly before withdrawing it.

If lesion is at bend use a flexible stent.

If stent/balloon placement is thought to be difficult use an extra-support wire.

When putting a stent for LAD ostium use LAO caudal and remember that balloon will come in left main.

Note that even left main can go in spasm, it usually happens during guidewire manipulation or guiding catheter manipulation. If you did not see the left main lesion in the diagnostic picture then there is no need to panic, take shots again after giving intra arterial nitrate.

Some stents with long stiff segments will not easily take a curve or angle.

If balloon ruptures during stent deployment

  • 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.

If there is calcification at curve then consider using a stent in sheath. Note that sheath delivery system is also useful if a calcified artery has developed a dissection.

In PTCA of an old vein graft, remember that if contents of this degenerated vein graft are embolized in the distal bed then patient is in trouble as even surgeon can not be of help here. Therefore in such a graft after passing the guide-wire

  • 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.

If you are deploying a stent covered with the endothelium of the vein, then try stitching it with 9-O proline and use a large lumen guide such as the DCA guide.

If using a hand crimped stent in the proximal LAD/Cx, be careful with the location of the proximal end as it can come in the left-main.

Keep checking the ACT during a prolonged procedure.

For PTCA of the internal mammary artery

  • 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.

When crossing a total occlusion when wire comes in true lumen after crossing the lesion then it tends to

  • 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 you are planning to embilise a bronchial artery try to be away from the branch supplying the spinal cord as the patient can develop paraplegia.

In PTMC if the LA is large septal puncture may be more useful.

During PTCA of carotid artery try to see that the wire does go in cranium.

  • 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.

Please do not ignore the advice of senior paramedical staff (Nurses, technicians etc.) as they do not go for ward round and OPD therefore they have seen more procedures than you have.

Some cases will go for emergency surgery(though rare now, courtesy stents), do not delay the decision to refer for surgery.

Avoid a feeling of overconfidence or act overconfident as an overconfident operator is more likely to commit mistakes.

Common causes of problem during a PTCA procedure:

  • Guiding catheter not properly engaging the ostium.
  • Forgetting to administer heparin.
  • Withdrawing balloon before it is properly deflated.
  • Air coming into the system.

If you have a VIP patient just try to do the case like any other case you perform normally. Being extracautious and taking extra efforts under pressure is not desirable and usually bring in some complication.


© 2007 All rights reserved.
Designed and Hosted by