Salman Arain
@realarainmd
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Interventional Cardiologist | Fellowship Program Director | CTO + CHIP enthusiast | CLI | PAD | Intravascular Imaging
Houston, TX
Joined November 2024
The Contrast Modulation revolution is here! I made this account to spread the word and share my experiences with this exciting and often misunderstood technique. It is NOT an alternative to conventional CTO PCI - but an adjunct. Please comment, critique, share! #contrast1st #HDR
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When Good Wires Behave Badly! 😯 Some thoughts on why (and how) floppy wires like the Runthrough NS can cause perforation. 🔑 Wires (like any piece of equipment) are ‘innocent’. 🔑 Complications happen when wires are used in suboptimal (often unusual) conditions. The entire discussion is fun to read. 🙏🏼
Such a great discussion! I agree - any wire can perforate under the ‘right circumstances’. Some thoughts: 1) Floppy wires typically perforate when the tip gets caught in a small branch - too small for a knuckle to form 2) Increasing pressure on the tip (transmitted via the shaft) ultimately overcomes tissue resistance allowing the wire to exit 3) 🔑 Thus the PREREQUISITES for floppy wire perf. include a small branch, absence of visible knuckling at the tip, and a thin walled vessel. 4) The force at the wire tip is related to the stiffness of the shaft. This gets amplified when the shaft is constrained - by vessel wall, organized thrombus, an MC etc… Thus it is easy to see how (and when) floppy wires can be dangerous. It is rare because all of the conditions are infrequently met! Great news for fans of the RT NS! 🙌🏼🤩
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Such a great discussion! I agree - any wire can perforate under the ‘right circumstances’. Some thoughts: 1) Floppy wires typically perforate when the tip gets caught in a small branch - too small for a knuckle to form 2) Increasing pressure on the tip (transmitted via the shaft) ultimately overcomes tissue resistance allowing the wire to exit 3) 🔑 Thus the PREREQUISITES for floppy wire perf. include a small branch, absence of visible knuckling at the tip, and a thin walled vessel. 4) The force at the wire tip is related to the stiffness of the shaft. This gets amplified when the shaft is constrained - by vessel wall, organized thrombus, an MC etc… Thus it is easy to see how (and when) floppy wires can be dangerous. It is rare because all of the conditions are infrequently met! Great news for fans of the RT NS! 🙌🏼🤩
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May I suggest that this is the perfect situation in which to do a tip injection - particularly if: - the lesion is long and/or tortuous - the occlusion has an atypical appearance (non-abrupt cutoff), or - the presentation is delayed Gentle injection of contrast will not display clot, but it will help you understand the nature of the occlusion and the vessel path.
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@SalikNazirMD @MichaelMegalyMD @mahesh_maidsh @SCAI @MyJSCAI @cvinnovations @ACCinTouch @ArkansasAcc @CRT_meeting @Hragy My Fellows tell me it is their favorite wire - with other attendings! On any given day, I am most likely to reach for a Samurai or Sion. But I also like to mix it up - to teach my fellows how different wires behave.
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@MichaelMegalyMD @mahesh_maidsh @SCAI @MyJSCAI @cvinnovations @ACCinTouch @ArkansasAcc @CRT_meeting @Hragy Whoa! This is an interesting take. Just as I was about to start using it routinely. 🙃 Tell us more Michael! Or better yet, show us the case. 😯
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@jbspadoni @mahesh_maidsh @SCAI @MyJSCAI @cvinnovations @ACCinTouch @ArkansasAcc @CRT_meeting @Hragy Agree. Or a wire knuckle perforation. These tends to make a slit through the terminal artery segment.
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I am tagging @Hragy. We were just talking about the Runthrough recently. Here is the proverbial “exception that proves the rule”. Floppy wires are safe and do not cause perforations - until they do! 😯 Obviously, there is more to this as we will find out. All devices are innocent until proven guilty in my book.
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Thank you. I stand corrected - I do see brisk extravasation from the PDA now. I missed it initially. Also, stunning of the AV node and/or a vagal response can blunt tachycardia. I don’t want to spoil the case for everyone else. But with a visible bleed, I would balloon tamponade first - usually a little proximally, then work on second access etc.
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RT @realarainmd: @mahesh_maidsh Thank you Mahesh. I see your point about whether this was #HDR. This is a heavily calcified artery and I s…
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@mahesh_maidsh #contrast1st is valuable is all three scenarios - a win, win, win! You should also consider it for your peripheral interventions.
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Thank you Mahesh. I see your point about whether this was #HDR. This is a heavily calcified artery and I see a branch adjacent to the MC tip. So it is likely you are in TL - and the contrast facilitated wire crossing through an eccentric microchannel. But this brings up a good question 👉🏼What is the difference between #HDR and #contrast1st? 🤔 🔑 To me, #contrast1st means the application of contrast at the start of the CTO PCI. It can have 3 outcomes: #HDR, EP contrast inflitration, or tip injection into a concealed microchannel. 🔑 In the strictest sense, #HDR refers to successful plaque modification which allows wire passage. It has to be IP (even if the wire doesn’t fully cross). Great outcome that led to a good discussion. 🙏🏼
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Thank you Mahesh. I see your point about whether this was #HDR. This is a heavily calcified artery and I see a branch adjacent to the MC tip. So it is likely you are in TL - and the contrast facilitated wire crossing of an eccentric microchannel. But this brings up a good point 👉🏼What is the difference between #HDR and #contrast1st? 🤔 🔑 To me, #contrast1st means the application of contrast at the start of the CTO PCI. It can have 3 outcomes: #HDR, EP contrast inflitration, or tip injection into a concealed microchannel. 🔑 In the strictest sense, #HDR refers to successful plaque modification which allows wire passage. It has to be IP (even if the wire doesn’t fully cross). Great outcome that lead to a good discussion. 🙏🏼
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Great result! Well done Said. 👏🏼 The rare STEMI where the culprit is heavily calcified and needs additional plaque modification. Re: burr size, 1.5 mm is usually safe in the mid LAD. Rota has a self centering action - so unlikely to perforate in a straight segment. Also, you can use the proximal segment to visually size it.
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@jbspadoni @Laserrman @KPujdak @UICcardfellows @AdhirShroff @mividovich @spiritus_bah @KhalilIbrahimMD @evandrofilhobr @TWilsonMD @SarojNeupaneMD @Babar_Basir @drandrewsharp To my mind, the no reflow is likely multifactorial from a combination of platelet activation + microembolization as well as spasm. Reperfusion injury is less likely in a non MI setting.
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In my experience, the response is variable. Ectatic RCAs often behave like degenerating vein grafts. The gradual increase in lumen diameter leads to a corresponding baseline low flow state + layered thrombus along the walls. The no reflow after PTCA can be just as troublesome to manage as in grafts. The response to all drugs and aspiration is variable. The worst case I ever had involved an 84-year-old RCA with a distal lesion. The patient ended up requiring ECMO support for two days! 😳
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@jbspadoni @UICcardfellows @AdhirShroff @mividovich @spiritus_bah @KhalilIbrahimMD @evandrofilhobr @TWilsonMD @SarojNeupaneMD @Babar_Basir @Laserrman @drandrewsharp Brilliant case! Great head scratcher. 👏🏼
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