Diagnostic catheters for coronary angiography

Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters

1. DIAGNOSTIC CATHETERS-CORONARY ASWIN R.M. 1

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3. FIRST CARDIAC CATHETERISATION In 1929 Werner Forssmann Rubber catheter T hrough his own antecubital Vein Upto the pulmonary artery 3

4. HISTORY OF CORONARY CATHETERIZATION Selective cannulation of coronory or injection of dye into coronary arteries were considered unsafe Random " Brute Force" Approach – Upto 50 cc contrast in 1-2 sec Phasic injections – electronic pressure injectors timed with cardiac cycle for intentional diastolic injection Methods of reducing cardiac output Acetylcholine arrest Elevation of intrabronchial pressure Occlusion aortography Differential o pacification of aortic stream 4

5. FIRST SELECTIVE CORONARY ANGIOGRAM Was an accident Dr Mason Sones in 1958 A fter withdrawing a catheter after ventriculogram cannulated the RCA unknowingly When contrast was injected for an aortogram selective opacification of RCA noted Designed Sones catheter and popularized the technique Several preformed catheters were later designed. 5

6. DIAGNOSTIC CATHETERS 6

7. ANGIOGRAPHIC CATHETERS 7

8. CORONARY CATHETERS 8

9. IDEAL CHARACTERISTICS OF A CATHETER Better Torque Control Increase Outer diameter Reinforced construction Pushability Increase Outer diameter Stiffer Material Decreasing overall part length Flexibility Decrease Outer diameter Material with less modulus of elasticity Increasing overall part length Trackability Radio-opacity Atraumatic Tip Low Surface frictional resistance Kink resistance 9

10. PARTS Usual length= 100 cm Secondary Curve depending on Aortic size , Access site , ostial characteristics Tertiary curve in some catheters 10 A) TIP LENGTH – Increased length offers more stability in target vessel at the cost of maneuverability in the parent vessel. B) PRIMARY CURVE – angle of the target vessel from its parent artery. C) SECONDARY CURVE -- width of the parent vessel. D) TERTIARY CURVE –normal curvature of the parent vessel. E) CATHETER LENGTH – Usually 100 or 110 cm

11. Over bent & Under bent catheters Underbent - Angle of catheter tip is larger outside the body than inside Difficult to manipulate, shape difficult to predict Difficult to do deep engagement Over bent- Angle of catheter tip is smaller outside the body, than inside Shape of overbent inside body-easy to predict Easier to manipulate 11

12. SIZE MEASUREMENT: FRENCH CATHETER SCALE: The French catheter scale is commonly used to measure the outer diameter of cylindrical medical instruments D(mm) = Fr /3 Most commonly in adults -- Diagnostic Catheters of 5 – 7 Fr size 12

13. Thick walled - Better pushability and torque transmission Accentuates pressure waveform-systolic overshoot & diastolic dips. Thin walled _ Improves monitoring, blood sampling & flushing abilities, decrease thrombogenicity . Disadvantage – less torque control, not suitable for high pressure injection. WALL THICKNESS 13

14. 14 CATHETER MATERIALS Angiographic catheters made from Synthetic and semisynthetic Polymers Dacron Nylon Polyvinylchloride (PVC) Polyethylene (PE) Fluoropolymers (PTFE) (TEFLON) Polyurethane (PUR ) Silicon Radio opacity by incorporating Ba , Bi , Ir

15. CHARACTERISTICS 15

16. Very maneuverable & flexible. Covered by polyurethane coating – reduce vascular trauma. Some have Nylon core-increase bursting pressure Nylon – great mechanical & physical strength, reduced friction coefficient – achieve high flow rate of fluids Eg - NIH Catheter , Original Sones Catheter. DACRON 16

17. Excellent memory Softer than polyethylene or Teflon – Less vascular trauma Increased thrombogenicity Reshaped if immersed in boling water. Eg – pigtail angiographic ( cordis ) catheters & original judkins catheters. POLYURETHANE 17

18. Stiffness inbetween Polyurethane & Teflon. More Thrombogenic than PVC, polyurethane Heat Mouldablity good Eg – pigtail angiographic catheters, judkins catheters POLYETHYLENE 18

19. Softest & flexible among all High friction coefficient- spasm. Increased thrombogenicity . Very poor tensile strength (memory) Cant be reformed. Most hydrophilic. Drugs absorbed- NTG, insulin, diazepam,thiopentone . Eg - Balloon-tip flow directed catheters. POLYVINYL CHLORIDE 19

20. Stiffest – no suitable for selective catheters Poor memory. Low friction coefficient. Eg – Brockenbrough catheters, transducer-tip catheters & introducer sheaths. TEFLON 20

21. CATHETER LAYERS 21 Outer Layer Reinforcement –usually stainless steel braid Determines torque and Kink resistance Outer coating to reduce friction and thrombogenisity

22. TIP : Tapering tip for Diagnostic catheters HUB : Metal or plastic, larger than catheter, tapered hubs – easier insertion of guidewire . TIP & HUB 22

23. SIDE HOLES Advantages Prevent catheter damping (occlusion of the coronary ostium ) Allow additional blood flow out of tip, to perfuse the artery. Avoid catastrophic dissections in the ostium of the artery Avoids Disengagement during Injections Disadvantages False sense of security because now, aortic pressure, and not the coronary pressure is being monitored. Suboptimal opacification Makes catheter tip weak - kinking at side holes 23

24. Catheter Choices 24

25. Catheter choice and size selection 25

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27. JUDKINS CATHETER Melvin Judkins in 1967 Preformed catheter Primary and secondary curve Tapered tip with end hole Designed for femoral route Little manipulation needed if used from femoral route 27

28. JUDKINS CATHETER Size 3.5to 6 by most companies Length 100 cm 4-7 French available Size 4 usually used Right radial access 0.5 less size used for left Coronary 1 larger size for right Coronary In aortic aneurysms heat modification for size 7 to 10 done Curve length = distance between P (primary curve) & S (secondary curve) 28

29. ENGAGEMENT Left Judkins Right Judkins 29

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31. Aortic width 31

32. AMPLATZ CATHETER Original catheter by K urt Amplatz Austrian Radiologist 1967 Right and Left comes in 3 sizes usually 1 ,2,3 with increasing curvature 0.75 size , increments of .5 and 4 size also available for AL 32

33. AMPLATZ LEFT Coronory ostia out of conventional judkins Like high and posterior origin It can selectively canulate LAD or LCX if short left main stem S eparate origins of left anterior descending and left circumflex coronary arteries. H igh anterior right coronary arteries (RCAs) or Shepherd’s Crook RCA. 33 While engaging the left coronary pushing the catheter will cause disengagement and pulling the catheter will cause deeper engagement of the Amplatz  catheter, due to its peculiar curve

34. AMPLATZ RIGHT Amplatz right coronary catheter can be used to cannulate right coronary arteries with abnormal, usually, an inferior origin or high anterior 34

35. Coronary anatomy Variation Coronary ostial location: High L ow Anterior Posterior Coronary ostial orientation (take offs): S uperior Horizontal Inferior Shepherd’s crook (RCA’s only) 35

36. Coronary Ostial take offs 36

37. SUMMARY RCA Normal origin And Course JR4 Anterior ectopic origin AR, AL , Hockey stick Inferior ectopic origin with inferior course MP Superior ectopic origin from ascending thoracic aorta with inferior course MP Superior course IM 3DRC Tortuous bend anatomy , posterior takeoff 3DRC Anomalous RCA from left sinus JL 5,6 AR 2,3, LMCA Normal origin and course Jl4 Large ascending thoracic aorta JL 5,6 Small Acsending thoracic aorta JL3 , 3.5 Anomolous origin from right sinus AR Anomolous origin of LCX from right sinus JR AR MP Separate origin of LCX LAD AR 37

38. MULTIPURPOSE CATHETER Initial multipurpose catheter by Schoonmaker & King In 1974 Developed to avoid the need of 3 separate preformed catheters for both coronaries and ventriculography from femoral route Similar to the Sones catheter Polyurethane catheter S ingle curve with straight tip an end hole and two side holes. 38

39. MULTIPURPOSE CATHETER A bend – hockey stick with straight tip 120 degree curve B bend -- gradual 90 degree curve MP A-1 : 1 end hole only MP A-2 : 2side holes ,1end hole MP B-1 : 1 end hole only MP B-2: 2 sideholes and an end hole Use: CAG – Both native vessel and graft , Ventriculography , Right heart catheterization With more specialized catheters its use has decreased 39

40. Other Catheters 40

41. RADIAL ACCESS 41

42. RADIAL ACCESS 42

43. RADIAL ACCESS Course of catheter 43

44. Difficulty passing to aorta 44

45. DIAGNOSTIC CATHETERS - RADIAL APPROACH Two catheter JR & JL AR & AL Single Catheter Standard femoral catheters – JL , AL , AR Universal /Bilateral catheters – Ex: Tiger , Jacky , Sarah (Terumo) Kimney (Boston Scientific) MAC 30-30 ( Medtronic) Ultimate Radial 1 & 2 ( M erit medical) Bilateral Brachial ( Cordis ) 45

46. Coronary Speciifc or Universal ?? 46

47. Tiger & Jacky Catheter B oth RCA and LCA with one catheter that can potentially: Limit catheter exchanges Shorten procedure and fluoroscopic time Lower cost per procedure Side hole Avoids intimal dissection during injection in non coaxial engagement prevents Kicking off during injections and Available in 5F & 6 F Nowadays used for transradial diagnostics more than any other catheter 47

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49. HEIGHT Very tall patients 100 cm catheters cannot reach upto coronary ostia Solution 110 cm Diagnostic catheters Multipupose catheter with 125 cm If radial prefer Left Radial access High radial puncture 49

50. WEIGHT Obesity Diaphragm moves cephalad Heart axis horizontal Short ascending aorta Counter clockwise rotation of coronary ostia RCA more anterior and LMCA more posterior take off If radial Left Radial has advantage over right 50

51. POST CABG Vessels to tackle LIMA RIMA Grafts ( ReSVG or Arterial) 51

52. SVG or ARTERIAL GRAFTS Usually Anterior surface higher up from sinus of vasalva Left coronary grafts - left anterior surface with circumflex grafts higher up Right coronary grafts -right anterior surface Ring markers often placed otherwise have to rely on surgeons report and previous angios JR catheter mainstay in graft angios 52 A – dRCA / dLCX ( in L dominant systems) B- LAD C- Diagonal D- LCX / OM / Ramus

53. Catheter selection Right Grafts Primary choice - MP Alternative – JR , RCB , AL Left Grafts : Primary Choice – JR4 , AL1 Upward trajectory may require - LCB , IM , HS More anterior origin – AL , HS > JR , LCB , MP 53

54. BYPASS CATHETERS RCB Resembles JR4 with a tip curved >90 degree LCB Primary curve similar to JR4 ( 90 degree ) but secondary curve more acute ( 70 degree) 54

55. POST CABG LIMA & RIMA Normal – IM , JR4 Origin from vertical portion of subclavian artery- JR4 , If radial - left radial approach is more suitable in patients with LIMA graft If Both LIMA and RIMA is to be canulated JR4 – can avoid catheter exchange 55

56. Internal mammary catheter Resembles Judkins right except for tighter primary curve (80degree) and longer tip 56 IM VB-1

57. Other Catheters for IMA BARBEAU RIMA 57

58. LIMA CANULATION Ease = Femoral = LRA>>RRA Techniques for LIMA cannulation with IMA catheters from RRA are described All of them based on passing a guide wire upto left elbow and catheter passed over wire 58

59. LIMA CANULATION Special Catheters for RRA LIMA also designed Ex: Yumiko Catheter 59

60. Right Gastroepiploic Usually to PDA Visceral angiographic catheter like cobra can be used Alternatively JR IMA For angiography non selective injection of coeliac trunk done 60

61. SUMMARY Burzotta F et al. CCI 2008;72:263-272 61 Pattern of Coronary Grafting Suggested primary approach LIMA LRA LIMA + RIMA RRA or Femoral LIMA + RIMA + RA Femoral LIMA + ReSVG (s) LRA ReSVG (s RRA or LRA

62. THANK YOU 62