Times of India
12 June 2010
By Pratibha Masand
Mumbai, India

City Doc Gives Sheath A Miss,But Jury Is Still Out On Safety Of Procedure
It was no regular angioplasty that Ghatkopar resident Birendra Singh underwent last week.Not only did the doctors make a tiny puncture on his right wrist instead of opting for the traditional groin route,the puncture itself was much smaller than usual,and the procedure ensured minimal invasion.A stent was inserted into 50-year-old Singhs arteries with a wire and a catheter;no sheath was used.

According to doctor Dr Narayan Gadkar,the interventional cardiologist in Kohinoor Hospital in Kurla (west) who conducted the procedure,the angioplasty Singh underwent guaranteed less pain and less dependence on medication at a slightly lower cost.(See box).Generally,after puncturing the artery with a wire,we introduce a sheath (a 2.8 mm diameter tube),through which we put a catheter that is generally 1.8 mm in diameter.But I tried a new method,in which we put in a catheter without the sheath, says Dr Gadkar.The innovation ensured 1 mm of less invasion in the patients artery and,hence,less pain.

Angioplasty is a procedure to open narrowed or blocked blood vessels (coronary arteries ) that supply blood to the heart.Singh,who suffered a heart attack on May 30,said: During the angiography,doctors at Kohinoor Hospital discovered there was a blockage in my arteries.

Dr Gadkar had already performed around 50 angiographies without the sheath,and after consulting with Singh,found an ideal candidate in him for the new procedure.Our only requirement was a different catheter for the angioplasty once we realised that the patient had a blockage.We put in a stent and a balloon,and the procedure was over in 30 minutes, said Dr Gadkar.But hes quick to add that the sheathless procedure can be hazardous to a patient if too much pressure is put on the artery.

The artery near the groin is a big one,and has space for even two catheters with sheaths.But the wrist artery is a thin blood vessel even thinner for Indians.When we insert a sheath in this artery,we are stretching it to a limit.If stretched beyond limit,the artery can burst,or the patient may suffer from hematoma and may even require a blood transfusion, said the doctor.

Stray cases where sheathless angioplasty has been performed in other countries have made it into medical journals.Nevertheless,the cardiology community here remains divided over the efficacy and safety of the new procedure.The sheath is often see as a protective measure.Said Dr Ameya Udyavar from Hinduja Hospital : Only a part of the sheath is inside the artery.The rest is outside,from where we administer medicines to control blood pressure.If something goes wrong with the catheter,we can remove it and insert another one through the same sheath,without puncturing the patient again, he said,adding that the new procedure could be used if done with care.

Dr Sudhir Vaishnav of Asian Heart Hospital said: A sheath is required for proper entry into the artery.The catheter,having a blunt tip,could traumatise the artery.There is no mention in the normal literature that it is safe to perform an angioplasty without a sheath.Under local anaesthesia,the patient will not feel any pain,no matter how big a tube you insert.

Sheathless Procedure

What Is Angioplasty

It is a method of expanded arteries that have become blocked,typically arteries leading to the heart,in which case the procedure is called coronary angioplasty

Traditional Method
A large artery,usually in the groin and at times,in the leg or arm,is punctured with a wire.A sheath is put through the wire.A catheter is inserted through the sheath and guided to the area that is blocked.The stents and balloons are guided through the catheter

Now
In the new procedure,instead of putting a sheath,the catheter is directly introduced into the artery after puncturing it with a wire There are different sizes available for catheters but the absence of the sheath will make a difference of around 1 mm in the diameter.The procedure will hence be less invasive

Benefits
The technique will be a boon for Indians,who are known to have smaller arteries,say docs The procedure will also be less painful There is a lesser chance of the artery being ruptured with the modified procedure The patient can move around immediately after the completion of the procedure,which takes around 30 minutes It will cost a patient Rs 1,000 less

A Word Of Caution
The medical community is divided over the benefits of a sheathless angioplasty.Many see the sheath as a necessary safety backup