1. 5F in 6F (7F) technique in DES era (Parent-child catheter technique)
Kyoto 2nd Red Cross Hospital, Japan
Naoto Inoue M.D. FJCC FSCAI
Today I will show you the special technique for the delivery of stent. Its name is 5 in 6Fr technique or paret-child catheter techinique. This mehod was mainly investigated by TERUMO company.

2. Key Points in DES era Simple procedure is recommended
Debulking device plays a small role except calcified or bifurcated lesion
Safe DES implantation is important

3. For the DES delivery Longer is better → 23, 28, 33mm stents are
frequently used
The deliverability of long stent is not good especially in the calcified or tortuous lesion
For the DES
We need the technique for the safe DES delivery

4. 1 Catheter selection RCA: Amplatz, Hockey, Champ LCA: XB, EBU, Amplatz
In complicated lesion we should initially use support catheter instead of Judkins catheter. For right coronary Amplatz, Hockey Champ are useful, for LCA XB EBU

5. I will show you example

6. 6F EBU catheter
We can get good backup support with extraback up catheter, We succeeded stent deployment for circumflex artery

7. 2 Pre dilatation ,pre debulking
Enough predilatation (high pressure, large balloon)
Rotablator (calcified lesion）
Enough predilatation is needed. Sometimes use high pressure or large size balloon

8. Strong guide cathe, enough pre dilatation, debulking failed
Buddy wire, Support wire
Anchor technique
Large size
guiding catheter
5F in 6F
guiding technique
If the use of strong cathe, enough predilaattion, debulking failed. Next step are yhe use of buddy wire, support wire technique. The second techniques qre the use of lare size guiding catheter, anchor technique and 5 in 6 technique.
Large size (7,8F) provide strong back up support, but we need to the change of sheath introducer so not be realized. Previously we use anchor technique routinely.

9. Anchor technique Side branch anchor Peripheral anchor
There are two types of anchor techniques. One is side branch anchor and another is peripheral anchor.
Side branch anchor
Peripheral anchor

10. Cross of balloon catheter
LCX guide wire
2.5mm balloon dilatation
LAD CTO
This a LAD CTO case. After successful guide wire penetration, 1.5mm balloon could not pass the lesion. So we used side branch anchor technique. Anchor balloon was inflated in the circumflex artery.
Conquest guide wire pass
But balloon cath. could not pass

11. Cross of balloon catheter
1.5mm balloon pass the lesion
1.5mm balloon could pass the lesion. However I am afraid of the damage of DES polymer using this method for DES delivery.

12. Anchor technique for CTO
As you know recently we can use many kinds of wire. BMW ATW Rinato Traverse wire are first choice wire but we don’t usually use for CTO. PT2, Shinobi and Whisper are hydrocoating wire, used for tight lesion including CTO

13. 5F in 6F(7F) technique 6F mother cath. (Heartrail Terumo Co.)
6F>0.070 inch (Launcher, Heartrail
Radiguide)
Cureently We use 5 in 6 technique. 5 Fr guiding catheter is 20 cm longer than original GC. If the mother catheter is larger than inch, child catheter easily cross in the 6 Fr GC.
5F child cath. (20cm longer than mother cath.
Terumo Co.)

14. 5F in 6F technique Hemostatic valve Hemostatic valve Yconnector
Heartrail 5Fr straight
Y connector
Heartrail 5Fr straight
Heartrail 6Fr
Heartrail 6Fr
This is an original style. Hemostatic valve is attached to the parent catheter, Y-connector is attached to the child catheter.
Hemostatic valve not good

15. 5F in 6F technique S670 could not cross the lesion
dissection
I will show you example. Dissection occurred at mid-LAD. S670 stent could not pass the lesion.
G.C.: 6F Heartrail JL 3.5
G.W.: BMW wire
S670 could not cross the lesion

16. 5F in 6F technique Balloon cathe. Guidewire 5F cathe. 6F cathe.
Advanced child cathe.
Balloon cathe.
Child catheter is advanced along the proceded balloon catheter.

17. 5F in 6F technique During stenting Post stenting Child catheter
We succeeded the safe DES deployment.

18. Artery model 6Fr 5Fr distance
By the way we made an arterial model and measured the distance of 5f catheter length from GC tip.

19. 5F in 6F ６Fr only 7Fr only 8Fr only 20 40 60 80 100 120 140 160 5 1020 40 60 80
100
120
140
160 5 10 15 25
Distance from 6F guiding catheter tip[mm]
Resistance[gf]
5F in 6F
６Fr only
7Fr only
8Fr only
At the 15 cm insertion from the GC tip, its backup support is equal to the 8fr GC.

20. I will show you the combination 5f in 6f and anchor technique
I will show you the combination 5f in 6f and anchor technique.The child catheter was inserted deeply by anchor balloon technique.

21. We succeeded the two Cypher stents deployment.

23. RCA tortuous calcified lesion HD patient
This is another case. Patient has HD from 10 years ago. You can see severe calcification in whole coronary artery.

24. Two step 5 in 6
In this case the advancement of balloon catheter was also difficult. So we used two step 5 in 6 technique. Firstly we iflated the balloon catheter before the stenotic lesion. Then we advanced child catheter after that balloon could cross the stenosis, And then child catheter was inserted deeply.

25. Method of 5F in 6F
The feeilng of action and reaction is very important. And we need keep tightly GW and ballooon catheter.

26. Alternative 5F in 6F (7F) technique
Child catheter goes across the stenotic lesion
No risk of stent dislocation
I will show you more developed 5 in 6 technique. This concept is that child catheter goes across the stenosis completely. So there are no risk stent dislocation and no risk of DES polymer peeling off.
No risk of DES polymer peeling off

27. CABG (LITA→LAD, SVG→PL)
Hemodialysis
50 y.o. male

28. Child catheter
狭窄部位

29. 2.5x18mm Cypher
3.0x13mm Cypher

30. 直後
慢性期

31. Vessel injury Air embolism Complication
Finally I would like to talk about the complication of 5 in 6 technique. No1 is vessel injury and No.2 is air embolism.

32. Vessel injury
In the top of LMT, severe perforation occuured. Fortunately in this case perforation was healed spntaneously. So care advacement of child catheter is needed.

33. Air embolism We have one air embolism
Air embolism will occur when child catheter is wedged
or angiography after stent deployment
No.2 is air embolisem. Child catheter has small inner lumen.

34. Safety use for 5 in 6F technique
Gently advancement of child catheter into the coronary
artery
Careful monitoring distal coronary pressure
Check the blood back flow from Y-connector just after
stent deployment

35. Thank you !!