A new advance in catheterization of uterine and pelvic arteries Rx Only Specifications Distal taper to 4F Transition to floppy, radiopaque section with hydrophilic coating 14.6cm Distance between the curves 5F proximal end Tip lengths: 2cm (Model 5580) 4cm (Model 5581) 6cm (Model 5582) Catheter Deployment Case #1 with still images and discussion (2cm distal tip catheter) Pelvic Arteriogram Initial pre-treatment pelvic angiogram via a right common femoral artery approach using an Omni flush demonstrates bilateral hypertrophied uterine arteries supplying an enlarged, myomatous uterus Contralateral Catheterization The Omni is used to place a Bentson wire over the aortic bifurcation. Then it is exchanged and the left uterine artery is catheterized using the Gandras catheter over a 0.035 inch angled Glidewire Contralateral Confirmation An injection of contrast confirms placement into the contralateral uterine artery. Embolization can begin safely. Contralateral Embolization Without spasm, flow-directed embolization of the contralateral uterine artery can proceed to stasis Forming Reverse Curve Once contralateral embolization is complete, the catheter is placed so the primary curve sits perched on the aortic bifurcation, usually by pushing the catheter in over a guidewire deeper into uterine a. or other internal iliac branch. Then the guidewire is placed at the level of the primary curve and thecatheter is pushed up into the aorta, forming the reverse curve. Ipsilateral catheterization - CIA Once a reverse curve is formed, the catheter can be pulled into the ipsilateral common iliac artery (CIA) by steering the tip to the right Ipsilateral catheterization - IIA From there, the right internal iliac artery (IIA) is catheterized by directing the tip of the catheter posterior and medially, leading with a Bentson or Terumo angled Glidewire. Roadmapping can be helpful for this step. Ipsilateral catheterization - UA The catheter is then pulled into the anterior division of the internal iliac artery, off of which the uterine artery (UA) arises. Roadmapping is helpful. This is done over Glidewire to engage the origin of the UA. Experienced operators may be able to select by puffing contrast without wire. Ipsilateral catheterization - UA Deeper seating into the uterine artery can proceed once the origin is engaged. Avoid too much wire into the artery which can cause spasm. Withdraw wire as the catheter is pulled in. If the UA is very tortuous a wire may be needed to straighten the artery to allow deeper seating. Ipsilateral catheterization - UA This particular uterine artery has a very acute angle and is extremely tortuous proximally, making the catheterization challenging. However, because of the flexibility of the Gandras catheter shaft and soft tip, the artery is engaged with minimal trauma without incident. Ipsilateral Confirmation Once catheterized, an injection of contrast confirms position in the uterine artery just beyond its origin Ipsilateral embolization Because there is no significant spasm or reflux around the catheter tip, the artery is occluded to stasis from this position using flow-directed embolization without incident Straightening and Removal Once stasis is achieved, the Gandras catheter is pushed into the aorta with a guidewire at the primary curve level and straightened over the bifurcation. At this point any loops that have been created can be reduced by torquing in the correct direction while pulling down on the catheter. A wire should remain within the length of the catheter to avoid knotting. From there the catheter is exchanged for a flush catheter for completion angiography. Completion Post-embolization images demonstrate no significant filling into the myomatous uterus with the remainder of the pelvic vasculature preserved Completion Pre and post embolization images Catheter Deployment Case #2 with fluoro loops and discussion (4cm distal tip catheter) Using roadmapping, the catheter is pushed over Glidewire into contralateral uterine artery to proximal horizontal segment. Note, only the tapered tip is within the uterine artery. Advancing deeper over 0.018” wire to avoid spasm Geometry of catheter over aortic bifurcation - note locations of primary and secondary curves Following contralateral embolization, the catheter is advanced into uterine artery in order to perch the catheter’s primary curve on the bifurcation before it is pushed into the aorta Ipsilateral catheterization without wire while “puffing” contrast – if very tortuous arteries then guidewire use recommended while roadmapping Ipsiliateral deep seating without guidewire – note the soft flexible tip minimized spasm Flexibility of catheter with tip deep in uterine artery Flexibility of catheter tip Straightening and removal of 4cm tip following ipsilateral embolization Catheter Deployment Case #3 with fluoro loops and discussion (6cm distal tip catheter) Deep seating 6cm tip on contralateral side without guidewire Injection following advancement demonstrates no significant spasm Geometry of Gandras 6cm tip at this time – note primary and secondary curves Catheterization of ipsilateral CIA Ipsilateral cath with roadmapping - note withdrawal of wire once origin engaged and then advancing without guidewire Injection confirms no spasm in a medium to small uterine artery following deep seating Deep seating of Gandras 6cm tip without wire - note ultra flexibility of tip of catheter Injection confirmed no spasm following deep seating. Why would you need to use a microcatheter? Flow-directed embolization without spasm can proceed Straightening of Gandras 6cm tip following ipsilateral embolization Gandras 6cm removal over bifurcation Gandras 6cm tip ipsilateral cath example #2 using roadmap in extremely tortuous artery over wire Injection showing ultra flexibility of Gandras 6cm tip following ipsilateral catheterization with no significant spasm Flow-directed embolization achieved without spasm using ultra flexible Gandras 6cm tip Why would you need to use a microcatheter when you can deep-seat this tip without spasm? The Optimal Catheter Catheterize both uterine arteries from a single puncture site • Quicker case • Less anesthesia • Less X-ray Flexible shaft to minimize longitudinal force on artery Tapered hydrophilic distal tip for atraumatic catheterization Hybrid ultra flexible soft distal tip to perform like a microcatheter • Microcatheters are very expensive! Low profile to minimize spasm The Gandras catheter is indicated to be used for delivering embolic materials and radiopaque media to selected sites in the vascular system. Diagnostic, embolic or therapeutic agents are to be used in accordance with specifications outlined by the manufacturer. Please see the Gandras Instructions for Use for a complete listing of indications, contraindications, warnings and precautions. Embedded images are representative of a typical UFE procedure using the specially designed Gandras catheter curve shape. USA CAUTION: Federal law (U.S.A.) restricts these devices to sale by or on the order of a physician. CAUTION: The Gandras catheter should be used by physicians with adequate training in the use of the device. Please see the appropriate product Instructions for Use for a complete listing of the indications, contraindications, warnings and precautions. Vascular Solutions, Inc. 6464 Sycamore Court Minneapolis, Minnesota 55369 USA 888.240.6001 763.656.4300 www.vascularsolutions.com This presentation is provided for your professional use and content of individual slides may not be modified without prior consent of Vascular Solutions, Inc. Gandras is a trademark of Vascular Solutions, Inc. ©2009 Vascular Solutions, Inc. All rights reserved. ML1906 Rev. B 03/09