Easy PCI – Some Tips on the Little Things

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Cath Lab Digest or HMP Global, their employees, and affiliates. 

Morton J. Kern, MD, with contribution and commentary by Paul Teirstein, MD.

Morton J. Kern, MD, MSCAI, FACC, FAHA
Clinical Editor; Interventional Cardiologist, Long Beach VA Medical Center, Long Beach, California; Professor of Medicine, University of California, Irvine Medical Center, Orange, California 

Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, and Opsens Inc. 

Dr. Kern can be contacted at mortonkern2007@gmail.com
On X @MortonKern

Something new to me always comes out of our interventional cardiology conferences. I was reminded of how difficult it can be to thread the angioplasty guidewire into balloon catheter as my eyes and hands have aged. It takes me longer and requires more effort to fit these together. Then I recalled what I learned at the last Scripps Cardiovascular Symposium, when Paul Teirstein shared with us a technique to make percutaneous coronary intervention (PCI) easier. He showed us how to load the angioplasty guidewire into the angioplasty balloon using a syringe barrel. I had seen but ignored Paul’s wire guide technique until just recently, when in the lab with the new fellow, I was loading the guidewire in the balloon and I had a real struggle due to my aging eyes and hands, and in part related to my morning coffee. I then recalled Paul’s tip to put the guidewire and balloon together using a syringe barrel (Figures 1-2 and Video). It was simple and quick — qualities that are especially important for senior operators like me. This ‘tip and trick’ prompted Paul and I to collect a couple of other things from the cath lab crew that I thought would be worth sharing.  

The Teirstein Wire Loading Method 

Paul Teirstein, MD:  I thought I’d add some comments. My technique of guidewire loading method uses the right angles of the syringe plunger, creating a trough in which the guidewire and balloon catheter will meet. I use a hemostat to stabilize the syringe plunger, another excellent idea. You should hold the catheter and wire in a straight line, and then advance them to each other. The trick is to hold the catheter arc downward, which is counterintuitive, but will only work this way. It helps if the syringe is lubricated by wiping with a wet gauze. It works with most syringe plunger sizes, but I prefer the 25-35 mL syringes. If you practice this about 20 times, you will become an expert. Mort tried the wire loading technique with another catheter and guidewire, and it also worked very well (Figure 3). Again, the technique works well if you need to backload the guidewire on the micropuncture system. The trick does not work if either catheter has a blunt nose, as shown in Figure 4.  

A Tip for Brachial Vein Access: Ultrasound and Micropuncture Needle

Morton Kern, MD: Because we are a radial-first lab, we prefer to use a brachial vein almost exclusively for right heart catheterizations. To me, it makes little sense to prep the arm for the radial artery access for your left heart cath and also use the groin with its additional prep time for the right heart cath. While generally safe, femoral vein access introduces an unnecessary complexity with its potential risk of femoral access site bleeding and patient discomfort. Without ultrasound guidance, brachial vein access can be difficult and time consuming.  

Like many labs, arm vein access can be obtained with a 21-gauge Angiocath (BD) either in the holding area or later in the lab after the radial artery sheath is secured. Some patients have no visible or usable superficial brachial veins. We routinely employ ultrasound imaging to see the vein (Figure 5) and using a metal micropuncture needle, visualize vein access without through-and-through punctures or inadvertent brachial artery puncture.  

For good brachial vein access, we prep the arm above the elbow and place a sterile rubber tourniquet ready to use after securing radial access (Figure 6). The tourniquet is applied, and a vein is imaged with ultrasound. Some veins are deep, while others are shallower. In the past, although we used a 21-gauge Angiocath, which worked well, we found the micropuncture needle has a smaller diameter and longer length than the Angiocath. The micropuncture needle is very smooth and unlike the Angiocath, has no edge between the needle and the cannula, the presence of which caused movement of the vein and failure of cannula insertion in some cases. We found that using a micropuncture needle and a metal wire can be more easily seen with ultrasound, and is introduced in an exceptionally smooth and rapid manner. We have switched over to micropuncture needle access for both deep and superficial vein access. Once the wire is in place, we then exchange over it for a 5 French (F) or 6F sheath for catheter introduction to the right heart. We secure the vein with Tegaderm and then flush.  

Knowing Your Guidewires for Bifurcation Stenting

One of the small tips for easy PCI in 2025 focuses on an easy way to keep track of your guidewires for bifurcation stenting. In the past, we marked wires with different gauze, clips, torquers, or wires of different colors. Even Paul Teirstein had, at one time, developed a holder for the guidewires to secure the diagonal wire and left anterior descending  (LAD) wire or other wires in a fixture (Figure 7) that clearly identified which wire was which, but that technique has gone by the wayside. 

Here is an especially easy way to identify which wire is in which branch. My technologist, Adam Garcia, was clever enough to take our marking pen and label the torque tools with the name of the artery in which this wire resides (Figure 8). The operators can clearly see which wire is which. One of the torquers is labeled “LAD” artery wire and the other is “Diag” for the diagonal wire. Using the labeled torquers, it is very easy to maintain control, and then use of the torquer if you need to reposition guidewires for bifurcation stenting. Although a very simple idea, I thought this was brilliant. Kudos to Adam.  

Easy Patient Status Awareness in the Lab

This last tip helps the team with patient status awareness, particularly for the contrast load and the patient’s renal function. I often say, “I’ve forgotten what his creatinine is,” or “What is his body weight…”, or something similar. To overcome this lapse and make things easy, we have an information board inside the lab. For each patient procedure, we display important information (Figure 9). Our technologists and nurses fill in the board at the beginning of each case. It’s easy to see, very handy, and helpful. Our fellows really appreciate this as well.  

The Bottom Line

I hope this brief collection of tips and tricks for easy PCI in 2025 is helpful. If you identify a tip or trick that makes PCI or intervention or cardiac cath easier in your lab, please consider sending it along to me at mortonkern2007@gmail.com with a picture and paragraph. We will highlight it in these pages. Here’s to having a great and safe 2025.