Catheters used in Angiography & angioplasty

Guide catheters are essential tools for Pecutaneous
Coronary Intervention
• Understanding construction, design & performance
characteristics facilitate their appropriate selection
• Selection of Guide catheters seems elementary but
makes the difference between a successful and failed
PCI procedure

1. Satyam J Shukla Diagnostic & Guiding Catheter used in PTCA

2. Components of Percutaneous coronary intervention equipment.

3. Diagnostic Catheter Guide Catheter Thicker shaft Thinner shaft Internal Dm Small Internal Dm Larger Tapering Tip Non Tapering Tip Less Reinforced More Reinforced Difference between Diagnostic & Guide Catheter

4. Diagnostic catheters Judkins L • Left radial JL 3.5 Femoral JL4

5. Judkins R – JR4 For Radial and Femoral Radial & Femoral – RCA- JR4

6. Multipurpose Radial - Tiger

7. Shapes used for coronary grafts

8. Diagnostic catheter shapes • Femoral – Judkins - JL4, JR4 – large JL5 – Small JL3.5 – Other - Williams, AL1 • Radial – Judkins - JL3.5, JR4 - Tiger Summary

9. The Guiding Catheter A special large-lumen catheter (5–8F) is used to deliver the coronary balloon catheter and other interventional devices to the target lesion.

10. Support for device advancement Path for device and wire transport Vehicle for contrast injection Measurement of Pressure Functions of a Guide Catheter

11. Parts of a Guiding Catheter Usual Length is 100 cm Tertiary curve is available in some Catheters

12. Guiding catheters are made up of three layers Inner polytetrafluoroethylene layer that is slippery, A middle stainless steel braided layer. Outer soft nylon elastomer jacket Cross section of catheter

13. Guide Selection The guide catheter is usually firmly supported against the aortic wall opposite to the coronary sinus from which the artery arises. Selection is dependent on Side holes French sizes[Fr] Length Type of curve Anatomy based Size of the aortic root Ostial origin and takeoff Support Active Support Passive Support • Anomalous origin

14. Side Holes Side holes prevent ventricularization or dampening caused by engagement of guide significant ostial lesions, misalignment of guides, during coronary spasm, or when a large Fr guide is used for engagement of a smaller coronary artery Advantages Disadvantages Maintains coronary artery perfusion False sense of security as it monitors aortic not coronary pressure Suboptimal opacification Increase in contrast volume TERUMO-Climber TM

15. French Sizes Ideally use the smallest diameter catheter feasible to minimize the risk of arterial damage. Larger French catheters have the advantage of improved opacifi cation , better guide support and allow for pressure. Usually 6 Fr guides will suffice for most interventions. 7 Fr: Two-stent strategy for bifurcation lesions and rotational atherectomy burr of 2 mm . Guide Length Regular 110 cm guides will suffi ce for most coronary interventions. Long saphenous vein graft (SVG) or internal mammary artery (IMA) grafts interventions may require the use of short 80 or 90 cm guides

16. Up to 250+ shapes available

17. Aortic width

18. Curve length = distance between P (primary curve) & S (secondary curve) •Aortic diameter determines the curve length Aortic width

19. GUIDE CATHETERS FOR TRANSFEMORAL INTERVENTION Most common catheters – Judkins – Amplatz – Extra Backup support EBU (Medtronic) XB ( Cordis ) Voda , Qcurve (Boston) • Catheters with niche use – Multipurpose – RCA graft, High LM takeoff – IMA cath – LIMA, Superior takeoff RCA or RCA graft – LCB, RCB cath – SVG

20. JL – primary (35°) Secondary(180°) and tertiary (35°)curve fitting aortic root anatomy engages LMCAostium without muchmanipulation JR – requires clockwiserotation to engage RCA Judkins

21. Judkins

22. The Amplatz Guide Secondary curve rest against the noncoronary posterior aortic cusp Offers firm platform for advancement of device Best in the case of a short LM, with downgoing left circumflex artery (LCX) Tip points slightly downward -higher danger of ostial injury causing dissection

23. The Amplatz Guide • Selection of the proper size for an Amplatz guide is essential – Size 1 is for the smallest aortic root – size 2 for normal – size 3 for large roots • Attempts to force engagement of a preformed Amplatz guide that does not conform to a particular aortic root increase risk of complication • If tip does not reach the ostium and keep lying below it - guide is too small • If tip lies above the ostium - guide is too large • When RCA ostium is very high - left Amplatz guide may be used to engage the right ostium

24. Long tip catheters (Extra Support) • Voda , XB, EBU • Advantages – coaxial intubation – better support & stability due to large area of contact between catheter & contralateral aortic wall – precise control and manipulation – lack of bends – improve advancement of devices,decrease the loss of supportive forces –Safety

25. Extra-Back-Up Guide • Long tip forms a fairly straight line with the LM axis or the proximal ostial RCA • Long secondary curve - abut the opposite aortic wall • So tip in the coronary artery is not easily displaced •Provide a very Stable platform

26. Multipurpose Guide • Straight with a single minor bend at the tip • For RCA bypass graft or a high left main (LM) takeoff

27. Other catheters 3 DRC – Three dimensional right curve - for tortuous, bent anatomy and posterior or superior take off of RCA • Arani Double angle 90° curve sits on ascending aorta in S configuration and is therefore useful for RCA with horizontal take-off & shepherd crook RCA Primary and secondary curve provides two contact points on the opposite side of aorta thus providing tremendous back-up

28. • El Gamal (EGB) - pre-shaped catheter with improved distal end-portion for accessing bypass grafts and more precise access of RCA • LCB - for left coronary venous bypass grafts. Its tip has 90 º bend with 70º secondary bend. • RCB - for right coronary venous bypass grafts, its tip and secondary bends approximate 120º - like a JR catheter with ashallower tip bend Other catheters

29. Aortic root •Normal JL4 •Dilated JL ≥ 5, AL ≥ 2, VL ≥ 4, , XB ≥ 4, EBU ≥ 4 •Narrow JL3.5, VL3.5, XB3.0, EBU3.5 • Orientation •Normal, Anterior JL, AL, VL, XB, EBU •Posterior AL, VL, XB, EBU •Superior JL, VL, XB, EBU Guiding Catheter Selection - LCA

30. Aortic root •Normal JR4, AL1, AR1 •Dilated JR ≥ 5, AL ≥ 2, AR ≥ 2 •Narrow JR 3, AL ≤ 0.75 Orientation* • Normal JR, AL, AR •Anterior, Superior AL, HS, MP •Inferior MP, AR, JR •Shepherd Crook AL, VR, VRSC, ELG, HS, IMA, Champ •Horizontal JR, HS, AR, VR Guiding Catheter Selection - RCA

31. Guiding Catheter Selection - SVG • RCA graft usual location : Primary – MP Alternate – JR, AL, RCB, HS, EGB • RCA graft anterior location : Primary – AL Alternate – JR, MP, HS • LCA graft : Primary – JR, HS Alternate : AL, LCB, MP, EGB (El Gamal ) • LCA graft ant location : Primary – AL, HS Alternate : JR, LCB,

32. GUIDE CATHETERS FOR TRANSRADIAL INTERVENTION

33. Choice of Catheters for TR-PCI • Left coronary artery: down size JL by 0.5 – Judkins left, Amplatz left, Multipurpose, EBU – Ikari left, El Gamal • Right coronary artery – Judkins right, Amplatz right, Amplatz left, Multipurpose, EBU-R – Ikari right, El Gamal • Single catheter strategy – Ikari left, Kimny , Barbeau , Fadajet

34. Guide catheter choices

35. Guide selection: L system guides

36. Guide catheter choices: EBU

37. Universal guide catheters Radial Brachial (RB) - Cordis

38. Terumo Ikari guide catheters

39. Guidewires used in the PCI

40. Guidewires : • Guidewires (solid wires navigated within the vascular system / extra‐ vascular tract) act as a lead point for catheters, allowing operators to traverse along a given vessel / track. • General Types of Guidewires : • Starting guidewires ‐ used for catheter introduction and some procedures. • Selective guidewires ‐ used to cannulate side branches or cross critical lesions. • Exchange guidewires ‐ are stiffer and used to secure position as devices are passed over the wire.

41. Length • Must be long enough to cover the distance both inside and outside the patient. •Must also account for access well beyond the lesion, so that access across the lesion will not be lost intraoperatively . •Usually varies from 145 to 300 cm. Diameter • Vascular catheters are designed with a guidewire port of specific diameter. •Most procedures are performed with O35 guidewires (0.035 in.). •Small‐vessel angiography requires 0.018–0.014 in. guidewires .

42. Purpose of the Guide wire • To access the lesion • To cross the lesion atraumatically • To reach far end of the vessel • To rail the devices into coronaries • To provide support for interventional devices

43. Components of Coronary Guide wire Core Tip Cover Core Material Stainless steel (SS): Strengths : provide optimal support, transmission of force, torque characteristics, But susceptible to kinking Nitinol :More Flexible & kink resistance But less torqueability than SS. Core Diameter Larger the Diameter Better the support & torqueability . Core Taper Continous or segmental Shorter tapers enhance the push force & pushability , while longer tapers enhance the flexibility Coronary Guide wire

44. Components of Coronary Guide wire Core Tip Cover The tip refers to the distal end of the guidewire . There are two types of tips. covered with coils (spring-tip guidewires ) polymer (polymer-tip guidewires ) 2 type Of Design Core to TIP Design - one-piece core where the core extends all the way to the tip with a variable taper Two-piece or shaping ribbon The core stops just before the distal tip. A shaping ribbon (a small piece of metal) bridges the gap between the end of the core and the distal tip (these wires have less reliable torque control) and a higher likelihood to prolapse . Coronary Guide wire

45. Components of Coronary Guide wire Core Tip Cover To maintain the overall diameter of 0.014 in., all guidewires have a specifi c surface coating: Hyderophobic Hydrophobic coatings are silicone based coatings which repel water and are applied on the working length of the wire, with the exception of the distal tip Advantages More controllable (and therefore less likely to dissect) • Provide better tactile feel Challenges • Poor trackability • Wire tip becomes stiffer, torque response increases, but less tip resistance is transmitted to the operator, making it easier to enter a false channel. Coronary Guide wire

46. Components of Coronary Guide wire Core Tip Cover Hydrophilic Coating Applied over the entire working length of wire including tip coils • Attracts water - needs lubrication • Thin, non slippery, solid when dry→ becomes a gel when wet – ↓ friction – ↑ trackability – ↓ Thrombogenic – ↓ tactile feel – ↑ risk of perforation Useful in negotiating tortuous lesions and in “finding microchannels ” in total occlusionschannel . Coronary Guide wire

47. The Amplatz super-stiff and ultra-stiff guide wires (Cook Medical, Bloomington, Indian are the mainstay for almost every case in stabilizing balloons across high-flow lesions and during stent implantation or valvuloplasty Different type of Guidewire & Their Uses (0.025 to 0.038 inch) coronary wires are important to have on hand to engage coronary fistulas and small tortuous arterovenous malformations. (0.014 inch) The Meier Backup wire (Boston Scientific) and Lunderquist extra stiff wire (Cook Medical) have been invaluable for transcatheter pulmonary and aortic valve implantation when tortuosity and calcification is a problem.

48. Guidewire Depend upon the Shapes of the Distal end Wires with various sized curves. The distal 1- to 20-cm end of a wire is often distinct in design and maneuverability from its remaining length; this end often determines a wire’s utility.

49. Shaping of the Guide wire

50. Selection of Guidewires The selection of a guidewire should be primarily determined by Vessel morphology Lesion morphology Device properties .

51. Guidewires for Standard Lesion Morphology A standard lesion is defi ned by the absence of complex characteristics A “workhorse or frontline” wire is most suitable for standard lesions. The workhorse wire, which accounts for about 70 % of all coronary wires used, is a fl oppy wire with atraumatic tip which provides low to moderate support. Guidewires for Chronic Total Occlusions For the more complex lesions, particularly chronic total occlusions (CTO), a stiffer wire with increasing support may be required.

52. Selection of Guide wires