Guide catheters in coronary intervention

Judkins, Amplatz, Ikari, Extrabackup, Guide catheters

1. GUIDE CATHETERS Dr. Rohit Walse Intervention Fellow SCTIMST, Kerala INTERVENTION FORUM

2. SCOPE Introduction Properties of guide catheter Guide selection Common guide catheters Radial guides Guide extensions

3. Introduction Guide catheters are the conduit for hardware delivery down the coronary arteries. Proper guide selection makes a major difference during the intervention procedure. Each guide catheter has its inherent properties – suited for specific situations.

4. Functions of a Guide Catheter Vehicle for contrast injection Measurement of Pressure Conduit for wire & device transport Support for device advancement

5. Features of guide catheter Preformed configuration – optimum support Adequate lumen and device compatibility Good torque control Kink resistance Atraumatic tip

6. Structure

7. Structure

8. Stiffness of guide catheter Shaft of guide catheter has differential stiffness. Proximal push zone has high stiffness. Distal tip is soft and flexible.

9. Stiffness of guide catheter

10. Guide vs Diagnostic catheter Diagnostic catheter Thicker shaft Smaller inner diameter Tapered tip Usually has 2 layered construction Guide catheter Thinner shaft Larger internal diameter Non tapered tip Has 3 layer reinforced construction.

11. Backup Force F – force required to deliver hardware down the coronary arteries ⍬ (theta) – angle subtended by the guide catheter on the contralateral wall of the aorta. Fcos⍬ - destabilizing force which tends to push the catheter upwards.

12. Backup Force Larger the angle ⍬, greater is the backup support. Larger the angle ⍬, lesser the destabilizing force (Fcos⍬). As angle approaches 90º, support increases.

13. Side holes Side holes are advantageous in situations where damping is commonly encountered RCA interventions CTO PCI PCI on unprotected LM Allows perfusion to occur while the guide is engaged at the ostia.

14. Size compatibility Guide catheters are available in standard, large and giant lumen sizes. In large and giant lumens, the outer layers are fused together to increase lumen area.

15. Size compatibility Commonly used guide sizes are 6F and 7F

16. Guide size

17. Guide catheter selection Depends on multiple factors Anatomy of aorta Access Target vessel – location of ostia Type of lesion Vessel tortuosity/angulation Hardware to be used

18. Guide co-axial Co-axial guide position is extremely important during procedure. Improves deliverability Reduces trauma and complications.

19. Guide support Ability to remain in position and allow delivery of hardware distally into the coronaries. Guide catheter support is mainly of 2 types – Passive support Active support

20. Passive support Strong Support offered by Inherent configuration of the catheter with good backup against opposite aortic wall Stiffness from manufactured material Additional manipulation is generally not required Mainly passive Eg . Amplatz

21. Active support Active support obtained by manipulation of guide catheter Guide manipulation – Catheter conforms to the aortic anatomy and gives support Deep intubation into the coronary ostia Eg . EBU

22. Guide support

23. Guide size

24. Commonly used guide catheters Judkins Amplatz Extra back up Multipurpose guide

25. Judkins Left (JL) Similar curves as diagnostic catheter (primary and secondary curve) Easy cannulation Intubates small segment of LM ostium – reduced trauma Ideal catheter in cases where LM ostia is diseased Guide support low (narrow point of contact on aorta)

26. Judkins Right (JR) Most common guide used for RCA interventions Primary, secondary and tertiary curve No point of contact on ascending aorta Poor guide support – may not be suitable in tortuous vessels

27. Curve selection Curve selection depends on Width of ascending aorta Location of ostia Orientation of vessel Proper curve essential for co-axial alignment.

28. Amplatz guide Secondary curve sits on the aortic cusp while primary curve cannulates the ostia. Very good backup support Deep intubation of ostia – chance of ostial dissection Not suitable in patients with ostial disease

29. Amplatz guide Commonly used – AL 0.75 and AL 1 Size selection according to aortic size – larger aorta may require AL 2 or AL 3. Amplatz guide can cause significant aortic regurgitation. Main use in tortuous vessels or difficult lesions (calcified plaque)

30. EBU (extra backup) guide Single primary curve and long tip Long tip allows co-axial engagement of LCA Very good passive support – large contact area with aorta Deep engagement of coronary ostia – risk of dissection Not suitable in patients with LM ostia disease

31. EBU (extra backup) guide Commonly used size – EBU 3 / 3.5 (femoral) 1st choice for LCA interventions

32. LCA interventions Most common – EBU/XB Left main disease/ostial lesion – Judkins left (JL) Tortuous anatomy/very calcified lesions - Amplatz

33. RCA interventions Most common – Judkins right (JR) Tortuous anatomy, CTO, calcific lesions – Amplatz (AL 0.75, AL 1) Superior take off RCA – JR, Hockey stick or Amplatz Inferior take off RCA – Multipurpose guide Shepherd crook RCA – Amplatz

34. Special RCA catheters 3DRC (3 dimensional RCA catheter) Designed to cannulate RCA with minimal torque. Suitable for ostial lesions

35. Special RCA catheters ARANI Double loop catheter (S configuration) Contact with aorta at 2 sites – very good backup support Useful in Shepherd crook RCA

36. Special RCA catheters Hockey stick Meant for superior and horizontal take off of RCA Higher support than JR

37. Extra Backup catheters for RCA

38. Trans-radial PCI Commonly used catheters – Left – EBU Right – JR, Amplatz Sizing – Downsize curve by 0.5 for radial procedures

39. Ikari catheter Modified Judkins Left catheter 3 differences in design from JL :- Curve proximally to overcome resistance at subclavian entry Shorter secondary curve Longer straight portion for more support

40. Ikari catheter

41. Ikari catheter Superior backup force Wider area of contact with aortic wall

42. Ikari catheter Ikari left can cannulate both LCA and RCA Available in 3 curves – 3.5,3.75 and 4

43. Extra backup in TR PCI

44. SVG interventions Usual catheters – Judkins right (JR) Amplatz left (AL) Multipurpose (MP) Hockey stick curve

45. Guide extension catheters Based on concept of mother and child technique Meant for delivery of hardware down the coronary – difficult tracking Provides more support

46. Guide extension catheters 145 cm length 120 cm proximal hypotube shaft 25 cm guide catheter segment Inner diameter = 1.45mm (0.057”) Outer diameter = 1.68mm (0.066”)

47. Sheathless Guide S heathless techniques with hydrophilic large lumen guiding catheters ( Eucath , ASAHI, Japan) H ydrophilic-coated sheaths - reduce the force required to remove them and prevent the occurrence of spasm, improving patient comfort

48. Practical Tips- Radial vs Femoral

49. Practical Tips- Radial vs Femoral

50. Practical Tips- Sizing of catheters

51. Practical Tips- Sizing of catheters

52. Practical Tips- Sizing of catheters

53. JL 4 JL3.5

54. CONCLUSION Guide catheters form the backbone of any intervention procedure. Adequate guide support is very important for smooth and fast procedure. Different guide catheters have different properties – suited for different scenarios. Special catheters are available for extra support and abnormal ostia. Guide extension catheters help to overcome problem of trackability and support in difficult anatomy and lesions.

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