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Sheath-in-Sheath Technique for Exteriorization of Body Floss Wire
Selected Techniques Sheath-in-Sheath Technique for Exteriorization of Body Floss Wire Uei Pua,1,2 Singapore, Singapore
In this technique, we describe the insertion of a second sheath into the primary sheath containing a guidewire that is meant to be exteriorized. The second sheath serves to open the valve of the primary sheath and creates a water-tight chamber for the guidewire to enter. The second sheath is then removed, exposing the successfully exteriorized guidewire. This technique is an useful adjunct to conventional guidewire exteriorization techniques during body floss procedures.
Through-and-through wire access or ‘‘body floss’’ technique is a well-known method for establishing raildwire between 2 access sheaths. It is commonly used in a wide range of advanced endovascular procedures ranging from small access procedures, like the transpedal peripheral angioplasties,1,2 to large access procedures, like complex aortic endografting (e.g., thoracic fenestration).3 This article fulfills our institutional criteria for ethics board waiver. Conventional technique involves snaring of the soft tip of the guidewire using an endovascular snare and exteriorizing the wire snare complex through the recipient sheath. An alternative to guidewire snaring is direct guidewire cannulation of the recipient sheath. This could be facilitated and cannulation time reduced by positioning the sheath opening along
1 Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore. 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Correspondence to: Uei Pua, Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; E-mail: [email protected] Ann Vasc Surg 2017; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2016.08.052 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: May 4, 2016; manuscript accepted: August 25, 2016; published online: - - -
the ‘‘outer curve’’ of the vessel where the wire tip will preferentially traverse (Fig. 1A, B), by placing the recipient sheath within close proximity to the wire tip (e.g., long sheaths) (Fig. 1B), or when there is a close match between the vessel size and the sheath diameter (e.g., 7F sheath within 6-mm vessel). The most appealing benefit is the cost saving of an endovascular snare. Challenge in guidewire exteriorization, however, arises when a snare is not used, in that the hemostatic valve in the recipient sheath prevents the guidewire from exiting the recipient sheath (Fig. 2A). Common techniques to overcome this limitation include: temporary disruption of the hemostatic valve by grasping the guidewire tip by passing an artery forceps through the sheath valve, dismantling the valve component, or disconnecting the valve chamber to retrieve the guidewire tip within the valve chamber. Another common method would be to remove the recipient sheath, with another operator advancing the guidewire and maintaining manual compression. If done correctly, once the entire recipient sheath is removed, the guidewire would be found sticking out of the arteriotomy site. The recipient sheath is then reintroduced over the exteriorized guidewire. The downside of these methods is the loss of hemostasis (albeit transient) when the hemostatic 1
2 Pua
Annals of Vascular Surgery
Fig. 1. A 67-year-old woman with a thoracic aneurysm underwent customized thoracic endograft implantation with a fenestration for the left subclavian artery. (A) Preloaded guidewire (arrow) and 7F destination sheath (arrowhead ) in the outer curve of the left subclavian artery. This location allows for easy direction cannulation of the 7F destination sheath by the preloaded guidewire. (B) Entry of the preloaded guidewire into the recipient sheath (arrow). (C) The guidewire is passed through the
entire length of the 7F destination sheath (arrow) and (D) enters the second sheath (arrow, 5F sheath) through the valve chamber of the first sheath (arrowhead, 7F destination sheath). (E) Once the guidewire tip is ‘‘buckled’’ in the second sheath (arrow), the second sheath is removed, exposing the guidewire which is then exteriorized. This technique creates ‘‘water-tight’’ chamber for easy exteriorization of a through-andthrough guidewire.
valve mechanism is disrupted or when the arteriotomy site is exposed without a sheath in situ. In addition, the recipient sheath removal and reintroduction method is only applicable to short vascular sheaths (e.g., 10 cm), because with long sheaths (e.g., 55e65 cm), the exteriorized
guidewire may not have sufficient length for reintroduction of the removed sheath. Furthermore, guidewire size mismatch (e.g., 0.018 inch exteriorized wire on a 0.035 inch vascular sheath) may pose challenge for sheath reintroduction. Finally, this technique would only be
Volume
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2017
Sheath-in-sheath technique 3
Fig. 2. Schematic drawing of the sheath-in-sheath technique for guidewire exteriorization. (A) When a guidewire successfully cannulates the recipient sheath, it is prevented from exiting due to the sheath valve. (B) A second sheath which is small is inserted into the recipient
sheath to divide the sheath valve and forms a second chamber for the guidewire to enter. (C) Once the guidewire is in the second sheath, the second sheath is removed, exposing the exteriorized guidewire. This technique is an easy and bloodless way of guidewire exteriorization.
suitable for reintroduction of small sheath sizes (e.g., 7F) which do not require serial track dilatation. To overcome these issues, we began using the sheath-in-sheath technique (Figs. 1CeE, 2). In this techniques, once the guidewire is within the recipient sheath, a second regular vascular sheath (standard 10-cm sheath) is introduced together with the dilator without a guidewire into the larger recipient sheath (Figs. 1D, 2B). The dilator divides the valve of the recipient sheath and is removed once the second sheath is within the recipient sheath (Fig. 2B). The second sheath is flushed as per standard technique. As a guide, we choose a sheath 2F smaller than the recipient sheath. This allows easy telescoping of the smaller sheath and maintains minimal caliber difference between the 2 sheaths, for ease of guidewire passage. The purpose of telescoping a second sheath into the recipient sheath is such that the second sheath would create a secondary chamber for guidewire passage beyond the hemostatic valve of the recipient sheath (Figs. 1E, 2B). By maintaining 5 cm of the second sheath outside the recipient sheath, the guidewire is advanced into the valve chamber of the second sheath and is buckled within (Fig. 2B). At this stage, the second sheath is removed entirely out of the recipient sheath
exposing the guidewire outside the hemostatic valve of the recipient sheath (Figs. 1E, 2C). As the system is created by the addition of a hemostatic vascular sheath, the entire set up is ‘‘water tight’’ and blood loss is negligible compared with other techniques. In summary, in the sheath-in-sheath technique, we exploit the hemostatic capability of a second sheath to breach the recipient sheath valve and create a secondary hemostatic chamber for the guidewire to enter and subsequently exteriorized. This simple technique allows for an almost ‘‘bloodless’’ extraction of a body floss guidewire, overcoming the limitation imposed by the recipient hemostatic valve with minimal additional equipment or maneuvers.
REFERENCES 1. Manzi M, Palena LM. Treating calf and pedal vessel disease: the extremes of intervention. Semin Intervent Radiol 2014;31:313e9. 2. Clark W. Re: ‘‘Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions’’. J Endovasc Ther 2013;20: 440e1. 3. Joseph G, Premkumar P, Thomson V, et al. Externalized guidewires to facilitate fenestrated endograft deployment in the aortic arch. J Endovasc Ther 2016;23:160e71.
In this technique, we describe the insertion of a second sheath into the primary sheath containing a guidewire that is meant to be exteriorized. The second sheath serves to open the valve of the primary sheath and creates a water-tight chamber for the guidewire to enter. The second sheath is then removed, exposing the successfully exteriorized guidewire. This technique is an useful adjunct to conventional guidewire exteriorization techniques during body floss procedures.
Through-and-through wire access or ‘‘body floss’’ technique is a well-known method for establishing raildwire between 2 access sheaths. It is commonly used in a wide range of advanced endovascular procedures ranging from small access procedures, like the transpedal peripheral angioplasties,1,2 to large access procedures, like complex aortic endografting (e.g., thoracic fenestration).3 This article fulfills our institutional criteria for ethics board waiver. Conventional technique involves snaring of the soft tip of the guidewire using an endovascular snare and exteriorizing the wire snare complex through the recipient sheath. An alternative to guidewire snaring is direct guidewire cannulation of the recipient sheath. This could be facilitated and cannulation time reduced by positioning the sheath opening along
1 Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore. 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Correspondence to: Uei Pua, Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; E-mail: [email protected] Ann Vasc Surg 2017; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2016.08.052 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: May 4, 2016; manuscript accepted: August 25, 2016; published online: - - -
the ‘‘outer curve’’ of the vessel where the wire tip will preferentially traverse (Fig. 1A, B), by placing the recipient sheath within close proximity to the wire tip (e.g., long sheaths) (Fig. 1B), or when there is a close match between the vessel size and the sheath diameter (e.g., 7F sheath within 6-mm vessel). The most appealing benefit is the cost saving of an endovascular snare. Challenge in guidewire exteriorization, however, arises when a snare is not used, in that the hemostatic valve in the recipient sheath prevents the guidewire from exiting the recipient sheath (Fig. 2A). Common techniques to overcome this limitation include: temporary disruption of the hemostatic valve by grasping the guidewire tip by passing an artery forceps through the sheath valve, dismantling the valve component, or disconnecting the valve chamber to retrieve the guidewire tip within the valve chamber. Another common method would be to remove the recipient sheath, with another operator advancing the guidewire and maintaining manual compression. If done correctly, once the entire recipient sheath is removed, the guidewire would be found sticking out of the arteriotomy site. The recipient sheath is then reintroduced over the exteriorized guidewire. The downside of these methods is the loss of hemostasis (albeit transient) when the hemostatic 1
2 Pua
Annals of Vascular Surgery
Fig. 1. A 67-year-old woman with a thoracic aneurysm underwent customized thoracic endograft implantation with a fenestration for the left subclavian artery. (A) Preloaded guidewire (arrow) and 7F destination sheath (arrowhead ) in the outer curve of the left subclavian artery. This location allows for easy direction cannulation of the 7F destination sheath by the preloaded guidewire. (B) Entry of the preloaded guidewire into the recipient sheath (arrow). (C) The guidewire is passed through the
entire length of the 7F destination sheath (arrow) and (D) enters the second sheath (arrow, 5F sheath) through the valve chamber of the first sheath (arrowhead, 7F destination sheath). (E) Once the guidewire tip is ‘‘buckled’’ in the second sheath (arrow), the second sheath is removed, exposing the guidewire which is then exteriorized. This technique creates ‘‘water-tight’’ chamber for easy exteriorization of a through-andthrough guidewire.
valve mechanism is disrupted or when the arteriotomy site is exposed without a sheath in situ. In addition, the recipient sheath removal and reintroduction method is only applicable to short vascular sheaths (e.g., 10 cm), because with long sheaths (e.g., 55e65 cm), the exteriorized
guidewire may not have sufficient length for reintroduction of the removed sheath. Furthermore, guidewire size mismatch (e.g., 0.018 inch exteriorized wire on a 0.035 inch vascular sheath) may pose challenge for sheath reintroduction. Finally, this technique would only be
Volume
-, -
2017
Sheath-in-sheath technique 3
Fig. 2. Schematic drawing of the sheath-in-sheath technique for guidewire exteriorization. (A) When a guidewire successfully cannulates the recipient sheath, it is prevented from exiting due to the sheath valve. (B) A second sheath which is small is inserted into the recipient
sheath to divide the sheath valve and forms a second chamber for the guidewire to enter. (C) Once the guidewire is in the second sheath, the second sheath is removed, exposing the exteriorized guidewire. This technique is an easy and bloodless way of guidewire exteriorization.
suitable for reintroduction of small sheath sizes (e.g., 7F) which do not require serial track dilatation. To overcome these issues, we began using the sheath-in-sheath technique (Figs. 1CeE, 2). In this techniques, once the guidewire is within the recipient sheath, a second regular vascular sheath (standard 10-cm sheath) is introduced together with the dilator without a guidewire into the larger recipient sheath (Figs. 1D, 2B). The dilator divides the valve of the recipient sheath and is removed once the second sheath is within the recipient sheath (Fig. 2B). The second sheath is flushed as per standard technique. As a guide, we choose a sheath 2F smaller than the recipient sheath. This allows easy telescoping of the smaller sheath and maintains minimal caliber difference between the 2 sheaths, for ease of guidewire passage. The purpose of telescoping a second sheath into the recipient sheath is such that the second sheath would create a secondary chamber for guidewire passage beyond the hemostatic valve of the recipient sheath (Figs. 1E, 2B). By maintaining 5 cm of the second sheath outside the recipient sheath, the guidewire is advanced into the valve chamber of the second sheath and is buckled within (Fig. 2B). At this stage, the second sheath is removed entirely out of the recipient sheath
exposing the guidewire outside the hemostatic valve of the recipient sheath (Figs. 1E, 2C). As the system is created by the addition of a hemostatic vascular sheath, the entire set up is ‘‘water tight’’ and blood loss is negligible compared with other techniques. In summary, in the sheath-in-sheath technique, we exploit the hemostatic capability of a second sheath to breach the recipient sheath valve and create a secondary hemostatic chamber for the guidewire to enter and subsequently exteriorized. This simple technique allows for an almost ‘‘bloodless’’ extraction of a body floss guidewire, overcoming the limitation imposed by the recipient hemostatic valve with minimal additional equipment or maneuvers.
REFERENCES 1. Manzi M, Palena LM. Treating calf and pedal vessel disease: the extremes of intervention. Semin Intervent Radiol 2014;31:313e9. 2. Clark W. Re: ‘‘Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions’’. J Endovasc Ther 2013;20: 440e1. 3. Joseph G, Premkumar P, Thomson V, et al. Externalized guidewires to facilitate fenestrated endograft deployment in the aortic arch. J Endovasc Ther 2016;23:160e71.