How to do a coronary sinus angiogram:
1️⃣Engage the CS in LAO, then confirm and advance the sheath in RAO. I use a MPA2 or AL2 coronary catheter inside CS sheath & find the CS with a long glidewire. If wire glides in w/o ectopy and is posterior in RAO, you're in.
#EPeeps
1️⃣Engage the CS in LAO, then confirm and advance the sheath in RAO. I use a MPA2 or AL2 coronary catheter inside CS sheath & find the CS with a long glidewire. If wire glides in w/o ectopy and is posterior in RAO, you're in.
#EPeeps
How to do a coronary sinus angiogram:
2️⃣So important to advance CS sheath in RAO. This allows you to see if you're off axis. In LAO, sheath may buckle in the RA & you'll never know until sheath falls out when you try to advance. RAO lets you see that & fix it by torquing sheath.
2️⃣So important to advance CS sheath in RAO. This allows you to see if you're off axis. In LAO, sheath may buckle in the RA & you'll never know until sheath falls out when you try to advance. RAO lets you see that & fix it by torquing sheath.
How to do a coronary sinus angiogram:
2️⃣Once os is engaged, advance sheath over wire and coronary cath in RAO (trust me). If at all possible, try to get sheath high up into the CS, beyond Vieussens valve, but stop before the vessel takes a turns around the superior margin.
2️⃣Once os is engaged, advance sheath over wire and coronary cath in RAO (trust me). If at all possible, try to get sheath high up into the CS, beyond Vieussens valve, but stop before the vessel takes a turns around the superior margin.
How to do a coronary sinus angiogram:
3️⃣If the wire hangs in the mid vessel, you are abutting Vieussen's valve. Usually if you torque wire a few times, your get through it. Don't be fooled & go into vein of Marshall. The wire needs to go up and around to GCV or you're not there.
3️⃣If the wire hangs in the mid vessel, you are abutting Vieussen's valve. Usually if you torque wire a few times, your get through it. Don't be fooled & go into vein of Marshall. The wire needs to go up and around to GCV or you're not there.
How to do a coronary sinus angiogram:
4️⃣It really pays to get sheath up high. You'll get a better angio & sheath won't fall out when you push contrast or advance lead. If you have trouble crossing Vieussen's valve, try a Merit Vert vein selector to steer wire and give you a rail
4️⃣It really pays to get sheath up high. You'll get a better angio & sheath won't fall out when you push contrast or advance lead. If you have trouble crossing Vieussen's valve, try a Merit Vert vein selector to steer wire and give you a rail
5️⃣In main CS, don't waste yr time doing non-occlusive angio, unless u need to confirm you're not in VOM or dissecting. Advance balloon only a little bit out of sheath. I use MDT Clarity & leave 1/2 balloon inside. OR-take @narrowQRS advice & withdraw sheath w/o advancing balloon
How to do a coronary sinus angiogram:
6️⃣This part's really important. Listen up.
Don't inflate the balloon yet. Don't blast contrast yet.
Give a tiny puff, < 1 cc. Make certain you see outline of the CS & the contrast washes out. This proves you are not in VOM or dissecting
6️⃣This part's really important. Listen up.
Don't inflate the balloon yet. Don't blast contrast yet.
Give a tiny puff, < 1 cc. Make certain you see outline of the CS & the contrast washes out. This proves you are not in VOM or dissecting
How to do a coronary sinus angiogram:
7️⃣Once you've confirmed you are in CS proper, inflate the balloon. For me, I use MDT Clarity parked 1/2 inside the sheath. It only take 3-4 cc to fill. If you push the whole balloon out, you are more likely to occlude a side branch.
7️⃣Once you've confirmed you are in CS proper, inflate the balloon. For me, I use MDT Clarity parked 1/2 inside the sheath. It only take 3-4 cc to fill. If you push the whole balloon out, you are more likely to occlude a side branch.
How to do a coronary sinus angiogram:
8️⃣Give another tiny puff of contrast. You should see rim of contrast welling up around the balloon. It should not wash out or look like a stain. If it washes out, you aren't occluding. If it looks stained, deflate and confirm it washes out.
8️⃣Give another tiny puff of contrast. You should see rim of contrast welling up around the balloon. It should not wash out or look like a stain. If it washes out, you aren't occluding. If it looks stained, deflate and confirm it washes out.
How to do a coronary sinus angiogram:
9️⃣Only after all these step, do you push contrast with any force. Now, on cine begin to push contrast. I like to start with RAO. Start with light force. Watch for any signs of dissection and stop immediately if you have any uncertainty.
9️⃣Only after all these step, do you push contrast with any force. Now, on cine begin to push contrast. I like to start with RAO. Start with light force. Watch for any signs of dissection and stop immediately if you have any uncertainty.
How to do a coronary sinus angiogram:
1️⃣0️⃣ Once you are certain dye is free flowing (we use 50/50), push harder. Watch for collateral flow proximal to your balloon. That's where most of the good target veins will be.
1️⃣0️⃣ Once you are certain dye is free flowing (we use 50/50), push harder. Watch for collateral flow proximal to your balloon. That's where most of the good target veins will be.
How to do a coronary sinus angiogram:
1️⃣1️⃣If you did good angio w good visualization & don't see good targets proximal to balloon, you are almost certainly occluding a big side branch. Pull back sheath/balloon, give little puff and you may see it. Reinflate proximal & try again
1️⃣1️⃣If you did good angio w good visualization & don't see good targets proximal to balloon, you are almost certainly occluding a big side branch. Pull back sheath/balloon, give little puff and you may see it. Reinflate proximal & try again
How to do a coronary sinus angiogram:
1️⃣2️⃣Unless the anatomy is perfect or you really need to conserve dye, do at least two projections. I start w RAO. For #2, LAO is usually better than AP, but if possible do all three.
1️⃣2️⃣Unless the anatomy is perfect or you really need to conserve dye, do at least two projections. I start w RAO. For #2, LAO is usually better than AP, but if possible do all three.
How to do a coronary sinus angiogram:
1️⃣3️⃣If 1st angio shows a great target, but doesn't illuminate whole tree, resist temptation to stop there. Be disciplined and do a proper study. You'll regret this if you put lead in that branch and get crummy numbers or phrenic nerve stim.
1️⃣3️⃣If 1st angio shows a great target, but doesn't illuminate whole tree, resist temptation to stop there. Be disciplined and do a proper study. You'll regret this if you put lead in that branch and get crummy numbers or phrenic nerve stim.
How to do a coronary sinus angiogram:
1️⃣4️⃣Strongly consider subselecting your target vein with inner catheter and doing subselective angiogram. These (almost) never need balloon occlusion and are commonly the best angio of the batch w < 5 cc. You may find more targets.
1️⃣4️⃣Strongly consider subselecting your target vein with inner catheter and doing subselective angiogram. These (almost) never need balloon occlusion and are commonly the best angio of the batch w < 5 cc. You may find more targets.
How to do a coronary sinus angiogram:
A well performed CS angio informs best lead choice & target vessel & only takes a couple min. Don't take shortcuts and try to do LV leads blindly.
Remember!
A suboptimal CS angio is far more common than suboptimal CS anatomy.
#EPeep
Fin/
A well performed CS angio informs best lead choice & target vessel & only takes a couple min. Don't take shortcuts and try to do LV leads blindly.
Remember!
A suboptimal CS angio is far more common than suboptimal CS anatomy.
#EPeep
Fin/
Cool thing about MDT Clarity ballon is that it fits inside inner sheath (i.e Attain 2 select, Merit renal, BSX acuity inner 90/130 etc) Standard Cook balloon and others are too fat. Comes in handy once in a while. You need this on your shelf.
Why multiple projections?
Sometime the vein takeoffs, especially of mid lateral branches look like it’s one place when it’s really another. In LAO, these takeoff visualizations open up and often, w mid lateral branches may new 1-2 cm more proximal than they look in RAO.
Sometime the vein takeoffs, especially of mid lateral branches look like it’s one place when it’s really another. In LAO, these takeoff visualizations open up and often, w mid lateral branches may new 1-2 cm more proximal than they look in RAO.
LAO also allows you to distinguish the great cardiac vein (anterior intraventricular) from an anterolateral branch. Often hard to tell which is which in RAO as then run on top of each other. In LAO, there’s no doubt. AIV runs down or to the left. Anterolateral goes to the right.
Why RAO?
The mid lateral and posterior/posterolateral veins are less foreshortened and you and see how the vein lays out before you. Easier to see if you are well engaged ,
The mid lateral and posterior/posterolateral veins are less foreshortened and you and see how the vein lays out before you. Easier to see if you are well engaged ,
