Left coronary engagement (radial focus): detailed steps, diagrams, tips, and case videos-Elias Hanna 

Great suggestion

-When you are going down through the ascending aorta (step 1), CLOCK torque slightly (10-20 degrees) with deep breath -To cannulate the LCA from above (step 3A), EITHER CLOCK or COUNTERclock may be used. I generally start with mild and clock, and I watch carefully the behavior of the catheter; if it is turning away from the LCA and about to fly out to the convexity of the aorta, I immediately reverse to counterclock. This is the most important skill to acquire. For EBU/CLS type of guide catheters, COUNTERclok is often more successful -If engaging from above does not work (3A), or if the aorta is sharply angled, try to engage by looping the catheter from below (3B), and if it does not get in, you pull it back, give it a slight torque, then loop it again in another plane. For EBU/CLS guide catheters, counterclock is often more successful for this part, Additional notes: -Counterclock can point JL anteriorly, but not always, as I explained in other videos. If the catheter secondary bend is sitting on the aorta, counterclock points you anteriorly, but in the absence of this hinge, clock points you anteriorly. Also, clock points the JL/Tiger catheter up, which often proves helpful as in the example 25:26 -Yes, there is a slight risk of dissection with those attempts, but it has never happened with me during those particular maneuvers. The risk is higher if you allow your catheter to dive too deeply in the coronary (eg pulling AL or pulling EBU guide to deeply dive it in the coronary)

Thank you. I actually just uploaded a talk about RCA and about AL maneuvering for both RCA/LCA/grafts

@@eliashanna8248 Superb.. thank you so much 👍

Great point. If that happens, consider 2 things: (1) try to pull the catheter until it is free, give it a slight torque to get it into a different plane, then attempt pushing it again; you may try that a couple of times; (2) if the latter does not work, the likely issue is that your catheter is too large and bulky for that aorta; thus, I would consider downsizing (for example, if you are using CLS 4, go down to 3.5, or 3.5 to 3). I had this issue twice this week with CLS 3.5 in patients with narrow aorta, I had to downsize to CLS 3

@@eliashanna8248 thank you Doctor

Good question. As I indicated between minutes ~16:30 and 19, we generally clock torque as we are getting down through the aorta to the right cusp. To engage using the U technique (from below 3B), or to engage using the straight technique from above 3A, either clock or counterclock or no torque at all may work, there is no definite rule. It is more frequently counterclock that works for the EBU U technique, but it really depends on how much clock you had done already to reach the left cusp (as you were going down the aorta then jumping to the left cusp). Some tips: -For the straight technique 3 A: as you are pulling with a slight torque, it is most important to QUCIKLY react to the catheter behavior. IF the catheter is about to fly out of the left cusp, you immediately reverse your torque; hence start with a slight torque and depending on the behavor, keep torquing in the same direction or reverse. -For the U technique 3 B: make sure the catheter tip is free over the left cusp as you are pushing it, not feeling stuck (you may need to pull and torque to free it). Then you may start with a slight counterclock during your push; if it does not work, pull back to straighten the catheter and free it and push again with a clock maneuver.