Right coronary engagement: detailed steps, troubleshooting, cases- Amplatz L manipulation-RCA guides
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- Опубликовано: 2 июл 2024
- 0:00 Detailed step-by-step RCA engagement. Femoral vs radial
09:07 Troubleshooting when catheter comes too low or too high
16:10 Case of elongated aorta
17:56 When to clock vs counterclock summary slid
19:24 RCA cannot be engaged in standard fashion: next thought?
25:10 Torquing tips in case of severe aorta/innominate tortuosity. How to avoid catheter kink and identify it
31:39 RCA arising from left cusp
35:37 RCA catheter damping. How to move from conus branch to RCA
40:19 How to maneuver Amplatz left. What guides to uses for transradial RCA intervention (not JR4)
Thank you Dr Elias Hanna. Your lectures are very informative for not only trainees but for the trained interventional cardiologists also. Keep the good work going on. Thanks again and my best wishes.
Simply outstanding sir...... No one teaches like you.... Very grateful to you.. Thank you
Very nice and comprehensive..thanks
Excellent.
Very well explained.
Waiting for your talk on LMS stenting.
Osteal body and distal
Fantastic as usual
Well explained👍
very helpful thank you very much for your effort... please do more
Deeply Thanks
Excellent
Well done
Thanks so much
Thank you
thanx u Dr ELIAS HANNA
Sir plz explain rca engagement for anamolous origin of rca sir
Our standard catheter for RCA is "ALR1-2", do you have any experience with it ? In my previous center, it was mainly AL0.75/1, which I found easier, but is not allowed in my current center because it's an "agressive" cath...
I am not familiar with ALR, it may not be available in the US. I looked it up, and it seems like an intermediate catheter between AL1 and AR2. AL is an aggressive catheter with a higher risk of dissection if one is not experienced with it. I suggest one gets experience using the more benign diagnostic AL catheter in diagnostic cases before using the AL guiding catheter.
Dear Dr. Hanna.
Thank you for all your efforts.
When you say torque and pull at the same time. the pull should be how much? often this point is frustrating as i couldnt find in the litterature how much pull we should do. Just minimal to transmit the torque in place? or a few millimeters to make it jump in the RCA immediately
Thank you
The RCA is at the top of the sinus of Valsalva, about 1.5 cm above the aortic valve. More importantly, it is important to understand the geometry. Look at Figures 09:07, 12:26 and 15:27. Early in one's career, it may be a good idea to use non-selective puffs, as I explain under 12:26:
-if you see the "nest" of the right sinus (cusp), you may be too low
-if you see the straight line of the aortic convexity, you are too high
-if you see the left coronary artery filling, you are in the left cusp, which also means you are too high compared to the RCA. Torque your catheter to point it to the right and push it back down to the valve/right cusp.
-The catheter tends to be pulled high in radial cases (vs tends to dive low and get stuck in the "nest" in femoral cases, where you need to exert more pulling tension while torquing)
-The catheter tends to be pulled too high when the aorta is elongated and horizontal, in which case the RCA origin is almost at the same vertical level as the aortic valve (16:40 and 17:06). You recognize that the aorta is nearly horizontal by the way the catheter is lying in the aorta
-If your puffs show you are in the right sinus (the "nest"), not too high, yet you cannot see any RCA filling non-selectively in LAO, it is time to consider that the RCA may have anterior takeoff. Try to engage the RCA by making the catheter look at you in LAO, rather than look to the right, or use RAO.
@@eliashanna8248 thank you very much for your excellent explanation. Much appreciated !
Thank you Dr Hanna for patiently repeating concepts. I canulate the RCA a lot easier now!!
prof i want to ask you a question>>>sometimes while engaging RCA the jR tip frequently points up to the conus and engage it>>>>if we pull the catheter out and open the tip to a little bit manually on the table while putting the wire in>>>then we try to engage and the tip will point down to the RCA ostium rather than conus ...please tell me >>does this acceptable idea??????
It is a good idea. However, I favor any of the following:
-If JR is not deep in the conus, keep clocking (to point to the more posterior RCA), while pulling on it to elongate it and make it point down
-If JR is deep in the conus, counterclock to disengage, then try to engage while further pulling on the catheter than you did the first time, to elongate it and make it point down
-Get a catheter that points more down, like JR5 or AR1
How we can download this pdf plz...
Thanks a lot dr Hanna
Today many doubts about engaging anomalous RCA cleared
But have a question
What is the actual mechanism of VT or VF if Conal branch is engaged ?
By pulling i end up in left cups any tips to avoid it
Good point. I have discussed this issue in other talks, esp the more recent one this year. ruclips.net/video/COFbu02J2Xs/видео.html AND ruclips.net/video/DCYUM9LhZA0/видео.html
It happens especially in upright/vertical ascending aorta and small cusps, where the catheter keeps jumping to the higher LCA level. At this point, the catheter is already too high.
When this happens, I would counterclock to make the catheter look toward the right, then push it down to the right cusp, see that it is falling to a lower level, then pull it with a clock. Keep the catheter low at all times: I often don't just pull, but pull and push to transmit the torque yet keep the catheter low at all times.
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