GENTLE FIRST INJECTION
In a Western European hospital one operator found
good pressure trace and the amount of first contrast injection was
as if he was taking a diagnostic shot. This artery was the only
patent vessel that the patient had, and it was supplying collaterals
to other areas. The contrast hung in the vessel and the patient
did not survive this diagnostic shot. It also created serious problems
in the intervention cardiology career of the operator.
First injection should always be very gentle and
small in amount and be sure that contrast clears away. In this way
you can avoid such disasters.
WIRE IN SHEATH WITH DILATOR
If you have inserted an arterial or venous sheath
and you want to change it to a different sheath, Be careful.
In a South Asian hospital an operator was not
able to locate the wire straightner and pushed the guide wire into
the sheath, to be exchanged, over the dilator. Dilator had accidentally
gone beyond the tip of the sheath. Note that it has a sharp edge
and when the next wire was being inserted the wire also went into
the vessel wall. The next sheath went in the vessel wall causing
major dissection in the femoral artery.
So when you are changing the sheath, arterial or
venous, please push the guide wire using the straightner and do
not use the dilator as a straightner. The straightner will not enter
deep into the sheath. and will not guide the wire into the vessel
wall and the wire will stay in the lumen of the vessel and as result
the next sheath will also stay in the lumen of the vessel.
Always use a guide wire with a “J”
tip.
In above patient the dissection was fortunately
against the blood flow and it sealed itself in one week.
LEFT MAIN OSTIAL STENOSIS
In a Western European hospital the operator was
unable to engage the left coronary system with a Judkins catheter
and he opted for an Amplatz-left. There was a marked pressure drop
with the canulation and injection. The catheter was disengaged,
and engaged again for the next shot. After the fourth diagnostic
shot patient collapsed and could not be resuscitated. After first
injection operator should not have used the amplatz again(decision
with hindsight).
If there is pressure drop or ventricularisation,
it warns about the left main ostial stenosis. Operator should aim
to finish the diagnostic shots with minimum possible injections.
He can leave the sheath in situ and retake further shots if not
satisfied.
The injection should not be forceful as it can
lift a plaque in the left main.
Avoid multiple canulations of left main when the
pressure is dropping and you disengage the catheter after injections
Failure to easily engage the left main is not
always wrong curve of diagnostic catheter or abnormal origin. Be
careful as it can also be left main ostial stenosis. Do not rush
for an amplatz, as it enters the ostium with support of its curve
and the push of curve can lift the atheroma.
A sinus shot will help you to exclude left main
ostial disease and increase the choice of catheters.
RE-USE OF PIG-TAIL CATHETER
In many countries the diagnostic and the PTCA
hardware is used several times. The pig tail catheter is especially
used several times. It can cause following problems
- Clot in distal segment
- In a South Asian hospital an overused pig-tail catheter caught
in aortic root and developed an angle. When pulled back it fractured
at the angle. With a snare the distal segment was caught and pulled
back. It did not enter the femoral sheath and required arteriotomy
to be removed.
Keep a count of reuse by marking the catheter every time, it is
used. Using a mark on the catheter solves this problem.
AORTA TO LV IN AORTIC STENOSIS
A. With pig-tail in aortic root take an aortogram
(required anyway for aortic regurge). In this the aortic opening
will be visible. In same view use a left amplatz catheter and point
the straight wire towards the opening.
B. Take aortogram as above. Place a sones B catheter
in root curving at the opening now gently rotate the Sones catheter
in clockwise direction and withdraw it, it will tend to enter the
valve so gently advance the wire.
In a South-Asian hospital in a middle aged female
patient, a straight wire was used to enter aortic valve. Note that
these wires have a relatively stiff tip. It went through the LV
and the pig tail also went in the pericardium. With the proximal
holes, it showed the LV pressures. Operator directly went for high
pressure cine without the test shot. She developed severe pain with
marked ST elevation(chemical pericarditis). She developed fever
and pericardial effusion. She was given Ibuprofen and cephalosporin
for 5 days. She totally recovered. This case teaches two lessons.
- Always have a test injection before high pressure injection.
- Use a soft wire to enter LV such as turmo or wholly wire. It
will not lift anything from the valve to embolise and it will
not go through the LV in pericardium
Above lady had an echocardiogram after 12 months, it did not reveal
pericardial thickening.
COARCTATION
Use a soft wire. The advantage is that it will not pierce the
aortic wall or a collateral
DISSECTION OF LEFT-MAIN
In a south Asian hospital an operator was using
a 7f left amplatz diagnostic catheter. It dissected the left main
and the patient had to sent for an emergency surgery.
When using amplatz be gentle.
If diagnostic catheter is tending to go into the
circumflex and not very easily going in the LAD take a smaller size
judkins and it will tend to go in LAD. If catheter is tending to
go selectively in Cx then a larger size catheter will tend to go
in Cx.
In another case, the guiding catheter was tending
to go into the circumflex, the operator after extremely anticlockwise
managed to bring it in the LAD but since it had a relatively larger
curve, it entered upto the mid-LAD and caused severe spasm of the
vessel.
AIR IN LV
In a Western European hospital an operator connected
the pig-tail to high pressure injector. He did not check with
flush injection and tried a cine run directly. A large amount of
air was injected (as there was no contrast in the injector) with
dire consequences.
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