Angioplasty of a totally occluded right coronary artery

A new 6 French (F) guiding catheter with a large, teflon-coated internal lumen (4.2F) was developed, permitting use of the standard ultralow profile (< 3F) over-the-wire system. This small coronary angioplasty system (6F-PTCA) was evaluated in 48 lesions in 45 of 137 patients (33%) who underwent coronary angioplasty between September 1990 and January 1991. The mean age was 64 years (range 49 to 82); 37 (82%) were male. The procedure was via the brachial artery in 28 patients (62%). The overall primary success rate was 96%. It was 100% via the brachial artery and 90% via the femoral artery. There were no major complications. The puncture compression time with the 6F-PTCA via the brachial artery and via the femoral and with 8F-PTCA via the femoral was 3.8, 9.6, and 16.9 hr, respectively (P<0.001), although the procedure time of the 6F-PTCA via brachial and via femoral and of the 8F-PTCA was not significantly different. The mean hospital stay was 3.1, 4.5, and 5.5 days, respectively (P<0.01). A small hematoma occurred in 2 patients (4.4%) after the 6F-PTCA and in 3 (3.3%) after 8F-PTCA, and a large hematoma (>5 cm) was noted in 7 patients (7.6%) after 8F-PTCA. These results indicate that coronary angioplasty using the over-the-wire system through the new 6F guiding catheter is technically feasible. Moreover, this approach, especially when advanced via the brachial artery, could shorten the he-mostasis time and facilitate early ambulation. © 1992 Wiley-Liss, Inc.     

Coronary angioplasty through a new 6 french guiding catheter

Coronary angioplasty through smaller-diameter guiding catheters using predominantly fixed-wire balloon systems has been possible, but has had some limitations. The purpose of this prospective, nonrandomized study was to investigate the results of percutaneous transluminal coronary angioplasty using a new 6F guiding catheter with over-the-wire balloon systems. Coronary angioplasty using over-the-wire balloon systems through a new 6F guiding catheter was evaluated in 79 lesions in 70 patients and then compared to randomly selected procedures using 7F guiding catheters in 70 patients performed over the same time period. Coronary angioplasty through 6F guiding catheters and over-the-wire balloons including 8 long (30-mm) and 3 perfusion balloons was successful in 94.9% of lesions and in 94% of patients. Coronary angioplasty through 7F guiding catheters was successful in 97.5% of lesions and in 97.1% of patients, respectively. Success rates between 6F and 7F guiding catheter groups were similar overall and for proximal, mid, distal, or complex (total, subtotal, or length > 10-mm) lesions. There were no failures to withdraw the deflated balloon into the 6F guiding catheter. Vessel opacification after dilatation with the guidewire across the lesion was similar between the 6F and 7F guiding catheter groups. The mean change in hematocrit for the 6F procedures (?1.4±3.7%) was significantly lower than for the 7F procedures (?3.3±3.2%, P<0.001). Coronary angioplasty using a variety of over-the-wire balloon catheters through a new 6F guiding catheter is feasible with success rates comparable to 7F guiding catheters. Angioplasty with this 6F guiding catheter reduces procedural blood loss compared to larger-lumen guiding catheters. © 1994 Wiley-Liss,Inc..     

The brachial artery method to transluminal coronary angioplasty

The development of a brachial artery guiding catheter for (percutaneous) trans-luminal coronary angioplasty is described. Three-hundred angioplasty procedures were attempted with 196 (65%) via the branchial and 104 (35%) via the femoral artery. The coronary stenosis was crossed in 202 attempts (67%); in 138 via the brachial (70%) and 64 via the femoral artery (62%). A successful angioplasty occurred in 117 via the brachial (85%) and in 50 via the femoral artery (78%). Successful angioplasty of the left anterior descending artery was equally effective with either technique. Successful angioplasty of the right coronary artery was more difficult (P < 0.05) using the femoral artery. An unsuccessful angioplasty with one technique was occasionally overcome by use of the other technique. No brachial artery complications were encountered. The brachial method to transluminal coronary angioplasty is an acceptable and complementary alternative to the femoral technique. Those laboratories contemplating percutaneous transluminal coronary angioplasty may desire to utilize both approaches.     

The kissing balloon technique with two over-the-wire balloon catheters through a single 8-French guiding catheter

Some of the newer over-the-wire coronary angioplasty catheters have shaft sizes of 3.0 French (F) or less. The inner diameter of modern 8-F guiding catheters is large enough to accommodate two of such balloon catheters. We report a kissing balloon procedure with two over-the-wire catheters through a single 8-F guiding catheter.     

Use of femoral artery guiding catheters via the left brachial artery for transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty using the right brachial artery has been described using either a cutdown and arteriotomy or a percutaneous entry. Each method requires the use of a brachial artery guiding catheter (Stertzer guiding catheter; (USCI). This communication reports the use of percutaneous entry of the left brachial artery and coronary angioplasty performed with femoral guiding catheters. In this manner coronary angioplasty has been successfully performed in 42 of 47 patients (90%) without major complications.     

Bailout techniques for failed coronary angioplasty using 6 french guiding catheters

Coronary angioplasty (PTCA) through 6 French (F) guiding catheters is feasible, although acute or threatened closure following coronary artery dissections may occur. This report describes our experience with the treatment of suboptimal results in 13 patients from a population of 144 patients who had PTCA through 6F guiding catheters. Patients were treated with a new low profile autoperfusion catheter (ACS®, Flowtrack40?) or with Palmaz Schatz stents, advanced through 6F guiding catheters. PTCA was performed via the radial artery in 11 pts (85%) or via the femoral artery in two patients (15%). In two patients, (15%) PTCA was complicated by an dissection associated with complete loss of flow (TIMI 0) and a dissection was considered to lead to abrupt closure in the remaining 11 patients (85%), despite the presence of normal flow. A Flow-track40? perfusion catheter was successfully applied in three of four patients. In one patient a persisting dissection after restoration of flow by a perfusion catheter was treated with three Palmaz Schatz stents. Implantation of Palmaz Schatz stents was attempted as primary technique in nine patients. In one patient the stent could not cross a dissection in the proximal LAD via the radial artery. With an 8F system via the femoral artery, two stents could successfully be deployed with the stent delivery system. In another patient the stent could not be advanced across a subtotal residual stenosis in a tortuous left anterior descending coronary artery. Despite normal antegrade flow and emergency bypass surgery, this patient developed a non-Q-myocardial infarction. In the remaining patients, the clinical course was uncomplicated. With the limitations of the bare stent technique kept in mind, applying bailout techniques such as perfusion balloons and implantation of bare Palmaz Schatz coronary stents should be considered for improvement of suboptimal angioplasty results in a selected group of patients after PTCA with 6F guiding catheters. © 1994 Wiley-Liss,Inc..     

The brachial artery method to transluminal internal mammary artery angioplasty

A new catheter technique to perform angioplasty of the right or left internal mammary artery coronary graft utilizing the brachial artery approach is described. Utilization of the ipsilateral brachial artery permitted cannulation of the internal mammary artery with preformed polyurethane Teflon-lined guide catheters. The coronary dilatation catheter was passed through the guiding catheter into the internal mammary artery. This technique permitted successful access into the ipsilateral mammary artery in eight patients, the left internal mammary artery graft in five and the right in three patients. The angioplasty procedure was successfully performed in seven of eight cases (spasm of the left internal mammary artery precluded successful dilatation catheter passage in one case). No brachial artery complications were encountered. In two cases, angioplasty was successfully performed in additional coronary vessels. Follow-up of 1-16 months (mean: 7.7 months) revealed no clinical evidence of restenosis. The ipsilateral brachial artery approach utilizing preshaped guiding catheters for visualization and introduction of dilatation catheters into the internal mammary artery graft is a safe and successful approach, and it is an acceptable alternative to the femoral technique.     

Transluminal coronary angioplasty: comparison of brachial and femoral artery methods

The brachial and femoral artery methods for (percutaneous) transluminal coronary angioplasty are compared. We attempted 901 angioplasties with 539 (59.8%) via the brachial and 362 (40.2%) via the femoral artery. The stenosis was crossed in 670 attempts (74%); in 410 (76%) via the brachial, and in 260 (72%) via the femoral artery. Successful angioplasty was achieved in 607 attempts (67%): in 370 (69%) via the brachial, and in 237 (65%) via the femoral artery. There was no difference between the techniques in crossing the stenosis or achieving a primary success. The left anterior descending artery stenosis was statistically more likely to be crossed than a stenosis in the right (p less than 0.001), circumflex (p less than 0.05), left main coronary artery (p less than 0.05), or saphenous vein graft (p less than 0.05); the left anterior descending artery stenosis was more likely (p less than 0.05) to be successfully dilated if the lesion were crossed (410 of 445 cases, 92%) than a right coronary stenosis (117 of 136 cases, 80%). The brachial and femoral artery methods are comparable techniques. Interventional angiographers performing coronary angioplasty should utilize the angiographic approach with which they are most familiar.     

Tampa bay catheter: A new guiding catheter for endomyocardial biopsy via femoral approach

Initially, endomyocardial biopsies were obtained almost exclusively using the jugular vein approach. Lately, the femoral vein route has gained popularity and in many centers, including ours, it is preferred. Despite this, guiding catheters specifically designed for endomyocardial biopsy via femoral vein approach are not available. Here, the experience with the Tampa Bay catheter, designed for endomyocardial biopsy using the femoral vein is described. From 1–1-89 to 1–31-90, a total of 486 endomyocardial biopsies were performed in 78 post-heart transplant patients (1–17, mean 6 per patient); 106 were performed via internal jugular vein (22%) and 380 (78%) via femoral vein. Of these, 100 were performed using the Tampa Bay catheter. The remaining 280 biopsies were done using a long sheath or a Judkin's right coronary angioplasty guiding catheter. Biopsy specimens were adequate for diagnosis of rejection in all 106 biopsies performed via internal jugular vein (100%) in 99 of 100 biopsies via femoral vein using the Tampa Bay catheter (99%) and in 274 of the 280 (98%) biopsies using the long sheath or the right Judkin's coronary angioplasty guiding catheter (NS). The femoral vein is larger and easier to find than the internal jugular vein. More important, complications such as right pneu-mothorax, Horner's syndrome, recurrent laryngeal nerve paralysis, and right phrenic nerve paralysis, known to occur when the internal jugular vein approach is used, can be completely avoided when the femoral vein approach is used.     

Tampa Bay catheter: a new guiding catheter for endomyocardial biopsy via femoral approach.

Initially, endomyocardial biopsies were obtained almost exclusively using the jugular vein approach. Lately, the femoral vein route has gained popularity and in many centers, including ours, it is preferred. Despite this, guiding catheters specifically designed for endomyocardial biopsy via femoral vein approach are not available. Here, the experience with the Tampa Bay catheter, designed for endomyocardial biopsy using the femoral vein is described. From 1-1-89 to 1-31-90, a total of 486 endomyocardial biopsies were performed in 78 post-heart transplant patients (1-17, mean 6 per patient); 106 were performed via internal jugular vein (22%) and 380 (78%) via femoral vein. Of these, 100 were performed using the Tampa Bay catheter. The remaining 280 biopsies were done using a long sheath or a Judkin's right coronary angioplasty guiding catheter. Biopsy specimens were adequate for diagnosis of rejection in all 106 biopsies performed via internal jugular vein (100%) in 99 of 100 biopsies via femoral vein using the Tampa Bay catheter (99%) and in 274 of the 280 (98%) biopsies using the long sheath or the right Judkin's coronary angioplasty guiding catheter (NS). The femoral vein is larger and easier to find than the internal jugular vein. More important, complications such as right pneumothorax, Horner's syndrome, recurrent laryngeal nerve paralysis, and right phrenic nerve paralysis, known to occur when the internal jugular vein approach is used, can be completely avoided when the femoral vein approach is used.     

Preliminary experience with 5 and 6 French diagnostic catheters as guiding catheters for coronary angioplasty

With the reduction in profile of balloon dilation catheters, until recently, it has been the internal dimensions and performance of the guiding catheter that has mandated the use of 7, 8 or 9 French (F) systems for the performance of percutaneous transluminal coronary angioplasty (PTCA). A new 5F catheter design (Sherwood Medical Co., St. Louis, MO) provided a large inner lumen (0.4") permitting use of 0.20-0.22" fixed-wire PTCA balloon catheters with good coronary visualization. Potential advantages include reduced coronary artery ostial trauma and catheter induced damping and enhanced patient comfort. We report our initial experience in 14 patients undergoing PTCA with a 5 and 6F guide/fixed-wire system. Mean age was 63 +/- 10 (43-78 years). PTCA indications: Cardiogenic shock (1), post-myocardial infarction angina pectoris (2), grade III angina (5) and unstable angina pectoris (6). Vessel attempted: Left anterior descending (3), circumflex (4), obtuse marginal (2), diagonal (1), right coronary artery (3), and internal thoracic artery (1). Twelve patients had femoral approach; two brachial approach. The USCI Probe (USCI Division, Billerica, MA) was used in 8 lesions and SCIMED ACE (SCIMED Life Systems, Maplegrove, MN) catheter in 7 lesions. Successful 5 or 6F guide/fixed-wire dilations reduced the stenosis (77 +/- 14 to 37 +/- 30%) and were successfully performed in 79% (11/14). One 5F patient required 8F guiding catheter and was dilated with 2.0 fixed-wire balloon. A second failed 5F PTCA could not be dilated with any larger conventional system. A third total occlusion could not be crossed with a guidewire or fixed wire balloon. No patient had a complication.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-tip guiding catheter: successful and safe for left coronary artery angioplasty.

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150-180 degrees) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, approximately 20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

Long-tip guiding catheter: Successful and safe for left coronary artery angioplasty

A long-tip guiding catheter was designed for angioplasty of the left coronary artery. Principal factors of guiding catheter function were identified, and the catheter's shape was designed to utilize them efficiently. Emphasis was placed on an overbent secondary curve (150–180°) for more precise catheter control. The distal tip of the catheter is 2 cm long in the 4.0 size and the primary bend is shallow, ～20%. A 1.5 cm long segment between the secondary and tertiary curves enhances stability and support. Catheter performance was studied during procedures on 90 patients; 89 patients underwent coronary artery angioplasty and one patient underwent diagnostic angiography. The success rate for angioplasty was 95% with no major complications. Mild pressure damping occurred in 18 patients, and mild catheter displacement from the left main coronary artery occurred in 24 patients. Catheter support was judged as excellent to very good in 82 patients. Judkins or Amplatz catheters were not required during this study. The observed disadvantages of the long-tip catheter were the risk of catheter buckling up during advancement into the left main coronary artery and, perhaps, a higher risk of pressure damping. Superselective engagement of the catheter in the left anterior descending or circumflex arteries may be a problem when the left main coronary artery is very short. This study showed the long-tip catheter to be safe and highly successful for angioplasty of the left coronary artery.     

A technique for changing a ptca balloon catheter over a regular-length guidewire

In 100 patients who underwent coronary angioplasty with more than one balloon catheter for a lesion, these over-the-wire balloon catheters were changed by using a regular-length guidewire. In order to change to another balloon, the inflation device was connected to the central guide wire lumen of the catheter after pulling back the catheter until the proximal end of the regular length guide wire disappeared. By pulling back the balloon catheter from the guiding catheter by applying a pressure with the inflation device, the balloon was taken out of the guiding catheter leaving the wire in the coronary artery. One hundred forty-nine of 163 attempted procedures were completed successfully. Our technique helped in performing a fast, safe, and reliable changing procedure compared to the procedure with an extended guidewire. © 1994 Wiley-Liss,Inc..     

New guiding catheter for transrad PTCA

A new guiding catheter for PTCA is described. In our department, 302 patients (405 lesions) underwent transradial coronary angioplasty using the 6 Fr Kimny guiding catheter since January 1996. The total engagement rate using the Kimny guiding catheter was 91.3% (370/405). The engagement rate after the modified Kimny guiding catheter was introduced in May 1996 increased to 96.0% (243/253). The stent delivery success rate was 98.4%. We had two dislodged stents. PTCA for both left and right coronary arteries in a single procedure with the Kimny guiding catheter was performed via the radial artery in 27 patients. In 24 of these patients (89%) we engaged both coronaries successfully. In the remaining 3 patients we switched to another catheter. Except for 4 patients with non-Q-wave myocardial infarction, no major cardiac complications were encountered. No major entry site-related complications were seen, and no patient required vascular surgery or blood transfusions. In one patient the Kimny guiding catheter tip caused a minor dissection of the LMT, but no ischemic event occurred as a result. In conclusion, the Kimny device is a useful PTCA guiding catheter for routine angioplasty and stenting. Cathet. Cardiovasc. Diagn. 43:344–351, 1998. © 1998 Wiley-Liss, Inc.     

The Feasibility of Systematic Use of a Combined Diagnostic and Interventional 6 Fr Guide Catheter in Patients with Suspected Coronary Restenosis

This prospective study assessed the feasibility of re-percutaneous transluminal coronary angioplasty for coronary restenosis using routinely the new 6 Fr diagnostic/interventional Diaventional catheter with a large internal lumen (0.057) in 80 consecutive patients. Two patients had restenosis on two vessels. The restenosed coronary artery more frequently was the left anterior descending coronary artery (52%). In the first six patients, the over-the-wire technique was used; in the other patients, we used a balloon-on-a-wire device or a rapid-exchange balloon catheter. With these latter techniques, angiographic visualization was satisfactory, even when the balloon was placed through the stenosis. The balloon size varied from 2.0-3.5 mm (mean 2.9 ± 0.4 mm). In two patients, an immediate recoil needed reintervention with the same equipment and yielded a satisfactory final result. All but one procedure (81/82) were successful (in one patient, a total chronic occlusion could only transiently be reopened). However, in four patients, a complementary 6 Fr or 8 Fr technique, using standard guiding catheters, had to be used for a large dissection (two patients) and for failure to cross a tight stenosis (two patients). The overall success rate was 94% (77/82), with a 9.2% reduction of the total cost of the invasive procedure. In coronary restenosis, the use of the new 6 Fr diagnostic/interventional Diaventional catheter is possible with an excellent overall success rate and a reduction of the total cost of the invasive procedure.     

Early experience of transluminal coronary angioplasty (TCA) by the brachial artery (the sones technique in transluminal angioplasty)

Sixteen translumlnal coronary angioplasty procedures (TCA), eight right coronary artery (RCA) and eight left anterior descending coronary artery (LAD), by the brachial artery cut-down approach, were attempted with 9/16 (56%) immediate successes and 2/16 (12%) early recurrences. The procedure success rate for RCA obstructive lesions, 6/8 (75%) was greater than for LCA obstructions, 3/8 (38%). In six unsuccessful procedures the balloon catheter could not be advanced into the lesion, and in one unsuccessful procedure dissection of the coronary artery proximal to the lesion occurred. The brachial (Sones) technique for transluminal coronary angioplasty permits the use of softer guiding catheters for selective probing and approach to the coronary lesion but may be more likely to induce coronary spasm. Complete and high-resolution pre TCA anglograms with multiple views to disclose the exact anatomy of the coronary artery and Its lesion Is essential to ensure successful dilatation.     

Entrapment of a kinked catheter in the radial artery during transradial coronary angiography

The transradial approach is currently popular for vascular access during percutaneous coronary angiography and intervention. Catheter kinking during catheter manipulation is not uncommon, but mostly the kinked catheter can be unraveled by gentle rotation of catheter in the opposite direction. We describe a case in which the diagnostic catheter was kinked and entrapped in the small radial artery during transradial angiography. Attempts to withdraw or to unravel the catheter with gentle rotation were unsuccessful. We were able to catch the catheter tip with a 6 Fr Amplatz goose-neck snare kit (ev3, Inc.) guided by an 8 Fr guiding catheter via right femoral approach. We pulled the kinked catheter up into the brachial artery with large diameter where successful unraveling was possible, allowing for its successful removal through the radial sheath.     

A prospective randomized trial comparing the benefits and limitations of 6Fr and 8Fr guiding catheters in elective coronary angioplasty: clinical, procedural, angiographic, and economic end points

OBJECTIVES: To determine the relation between guiding catheter size, procedural and angiographic details, and cost of coronary angioplasty. BACKGROUND: Miniaturized angiographic equipment used during coronary angioplasty is proposed as a method to decrease the duration of supine bed rest, length of hospital stay, and cost of expensive inpatient hospitalization. METHODS: One hundred and sixty patients were randomized to undergo elective coronary angioplasty with a 6Fr (external diameter, 0.079-in; internal diameter 0.062-in) or 8Fr (external diameter, 0.105-in internal diameter, 0.078-0.079-in) guiding catheter. Standard balloon dilatation catheters were used. End points: 1 degree peripheral vascular complications, 2 degree technical and procedural outcomes; quantitative and qualitative quality of the coronary angiograms; and the in-hospital ("bottom up" cost accounting of equipment, supplies, support personnel, postcoronary angioplasty room), and physician cost (using Resource Based Relative Value Scale). RESULTS: There was no difference in peripheral vascular complications between the two groups (6Fr, 21%; 8Fr, 30%; P = NS). Less contrast medium was used with the 6Fr guiding catheters (6Fr, 178 +/- 102 mL; 8Fr, 257 +/- 147 mL; P = 0.0001). The qualitative quality of the angiograms was better with 8Fr than with 6Fr guiding catheters. For the entire population, the total cost of coronary angioplasty was less with 6Fr guiding catheters ($3,956 +/- $2,415) than with 8F guiding catheters ($5,073 +/- $3,985, P = 0.03). Excluding patients with either a coronary or peripheral vascular complication, there was less cost savings (6F, $3,720 +/- $1,338; 8F, $4,376 +/- 2,699, P = 0.05). Independent variables associated with increased cost included: large body mass index; hypercholesterolemia; nonionic contrast media; 8F guiding catheter; complex lesions; and duration of procedure. CONCLUSIONS: The use of smaller guiding catheters led to use of less contrast medium with a modest decrease in angiographic visualization. The cost savings seen with 6F guiding catheters is multifactorial due to smaller arteriotomy accompanying sheath insertion and reduced rate of clinically significant coronary and peripheral vascular complications.     

Six hour ambulation after elective coronary angioplasty and stenting with 7F guiding catheters ald low dose heparin

BACKGROUND: Early ambulation after coronary angioplasty may reduce in-hospital stay and add to the patient's comfort. This approach, however, may increase the risk of insertion site related complications, such as arterial bleeding, haematoma, pseudoaneurysm, and the need for surgical repair. AIM: To evaluate the feasibility and safety of ambulation of patients six hours after elective coronary angioplasty or stenting, or both. METHODS: Coronary angioplasty and stenting were performed using 7F guiding catheters via the femoral or brachial approach. The first dose of heparin 5000 IU was given immediately after insertion of the arterial sheath and the second dose heparin 2500 IU was given 90 minutes later. There were no angiographic exclusion criteria. The arterial sheath was removed immediately after the procedure. Haemostasis was achieved by manual compression and maintained with a compression bandage. Early ambulation was attempted after six hours of supine bed rest following removal of the bandage. The incidence of bleeding at ambulation requiring compression and additional bed rest, and insertion site complications documented 48 hours after the procedure, were analysed. RESULTS: 326 patients (290 femoral, 36 brachial route) were included. Stent implantation was performed in 267 patients (82%). The mean+/-SD time to haemostasis was 14+/-4 minutes. Bleeding at ambulation occurred in 7 (2.14%) patients, and major haematomas were seen in 8 (2.45%) patients during 48-hour follow up. All were seen in patients in whom the femoral route was used and who were treated conservatively. There were no late bleeding or vascular complications. CONCLUSIONS: Ambulation six hours after elective balloon angioplasty or stent implantation with 7F guiding catheters using femoral or brachial route and low dose heparin is feasible and safe, with a low incidence of insertion site complications. This early ambulation protocol shortens hospital stay.