Essentials of Catheter Selection

Essentials of Catheter Selection:
Optimizing Engagement and
Support
Carlos E. Alfonso, MD
Cardiology Fellowship Program Director
Associate Professor of Medicine
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Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
None
Consulting Fees/Honoraria
Merritt Medical
Major Stock Shareholder/Equity
None
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None
Ownership/Founder
None
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None
Other Financial Benefit
None
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TRA: Mechanisms of Failure
Total number of Failures
98/2100 (4.6%)
Failure of arterial access
Inadequate arterial puncture
13%
Failure to advance catheter to ascending aorta
Radial artery spasm
34%
Radial artery dissection
10%
Hydrophylic sheaths not used
Radial artery loop/tortuosity
6%
Radial artery stenosis
1%
Failure to complete PCI due to lack of guide support
Subclavian tortuosity
18%
Inadequate guide backup support
17%
n=2,100
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Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
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Understanding the Catheter’s Course
Right Radial
2 points of resistance
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Left Radial
Femoral
1 point of resistance
1 point of resistance
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Effect of Inspiration
α
A
α
B
Panel A: During expiration there is a more acute angle (α) between the brachiocephalic trunk and the ascending aorta, therefore
the wire takes a more horizontal a more horizontal direction towards the descending aorta. Panel B: During deep inspiration, the
diaphragm lowers the heart and straightens the angle (α) between the brachiocephalic trunk and the ascending aorta. The wire
takes a more vertical direction towards the ascending aorta.
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Radial Side Selection
The back-up force provided by the
guide catheter
differs according to the radial side
– Courtesy Francesco Burzotta
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• TALENT TRIAL:
Right vs. Left
Radial Cross-over
Overall 14 puncture
and radial failure vs 1
epi-aortic failure,
p= 0.0008
P= 0.70
RRA (n= 770)
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LRA (n= 770)
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Cases
to Femoral:
Incidence and
Classification
P= 0.41
2
P= 0.31
P= 0.31
Severe spasm
Subclavian-aortic
tortuosity
1
0
Lack of radial
canalization
Puncture Failure
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Radial
tortuosity/anomalies
Radial Failure
Epi-Aortic Failure
Sciahbasi A et al. Am Heart J 2011;161:172-9.
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TALENT TRIAL: Right vs. Left Radial
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Operator’s experience matters
Sciahbasi A et al. Am Heart J 2011;161:172-9.
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Catheter selection
• Learning curve
• Single vs. Double catheter technique
– Judkins: JL3.5 and JR4 or 5
– Single catheters:
• Tiger, ULT1, Jacky, ULT2, Sarah, ULT3, Kimny, Fajadet
• TRA PCI
– Right: JR4 or 5 – Left: EBU 3.5
– Single Catheter Technique: Ikari L
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Diagnostic Radial Catheters
•
•
•
•
Merit Ultimate 1
Merit Ultimate 2
Merit Ultimate 3
Merit Ultimate 4
These are radial
catheters used to
cannulate the right and
left coronary arteries
with just one shape.
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Ultimate 1 and 4
• The Ultimate 1 and 4 are come from the Judkins Left catheter
• This is why they are the most popular of the Ultimate
catheters.
Ultimate 1 and Ultimate 4
are just a relaxed version of
a Judkins Catheter
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Ultimate 1 – why it’s better than the Tiger
• The Tiger has a pinch point that makes it vulnerable to fold back on itself.
• The tertiary curve allows for added support.
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Ultimate 2 and Ultimate 3 – from Amplatz
3.5cm
4.0cm
Ultimate 3 (4.0cm)
Terumo Sarah
Ultimate 2 (3.5cm)
Terumo Jacky
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Good for dilated
roots where you
need extra reach
Ultimate 2 and 3 are more like
Amplatz catheters that get
support at the bottom of the
aortic root and give you more
“reach”
Ultimate 3
• The Ultimate 3 is an
Ultimate 2 layed out a little
further.
• This catheter is for dilated
aortas or extreme takeoffs.
Ultimate 3
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Most frequently used diagnostic coronary catheter shapes
ULT1
ULT4
Tiger
Jacky
Amplatz Left
LCB
Judkins Left
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Judins Right
Multipurpose A2
IM
3D LIMA
RCB
IM VB-1
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Catheter selection - Radial vs. Femoral
Radial
Hinge
Femoral
Femoral
Radial
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Ikari Y, et. al. Journal of Invasive Cardiology 200
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Catheter Selection: Femoral vs Radial
• Catheter Manipulation
Technique
– Transradial approach can
involve more tortuosity
than the femoral approach
– TRA necessitating small
(finger-based) clockwise
and counterclockwise
torquing movements and
active catheter holding as
there may be multiple
friction points in the
subclavian and the aorta
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JL 3.5 Radial
Different curve mechanics,
sizing and backup support
JL 4.0 Femoral
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Transradial Curves for Left Coronary – Extra Backup
Workhorse curve for left coronary artery
Sizing suggestions:
JL3.5 = EBU3.5
JL4.0 = EBU3.75
Comparable to:
Merit: SBS ConcierGE
Cordis: XB, XBLAD
BSC: Muta Left, Radial Curve,
Brachial Curve
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Apply torque to point the tip to the left coronary
cusp and turn catheter. Pull wire back and the
catheter will engage the left coronary artery.
Backup support from the sinus of valsalva
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Transradial Curves for Right Coronary Judkins Right
Standard curve for right coronary artery (may be
particularly useful for inferior takeoffs)
Sizing suggestions: Same as femoral approach
Comparable to:
Merit: Judkins Right
Cordis: Judkins Right
Judkins engagement technique, similar to
femoral approach. Apply a clockwise
rotation to engage right coronary artery
BSC: Judkins Right
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Transradial Curves for Right Coronary Judkins Right
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Deep intubation of RCA with JR4
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Comparison of Backup Force in TRI
B
A
IR
max resistance (g force)
JR
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C
D
AL
IL
160
140
120
100
80
60
40
20
0
JR4
IR1.5
AL1
IL3.5
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AMPLATZ for Complex PCI
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AMPLATZ for Complex PCI
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Guideliner Case / Mother-Child Case
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Guideliner Case
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Guideliner Case
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Guideliner Case
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Be Careful With Aggressive Guides
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Plourde G et al. AIM RADIAL 2013
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Plourde G et al. AIM RADIAL 2013
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Dedicated Radial Catheters Performa Ultimate
•
•
•
•
Merit Ultimate 1
Merit Ultimate 2
Merit Ultimate 3
Merit Ultimate 4
These are radial catheters used to cannulate
the right and left coronary arteries with just
one shape.
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Jacky Catheter: Selective Engagement of RCA and LM
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Using JL 3.5 as Universal Catheter
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Using JL 3.5 as Universal Catheter
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TRA in Patients with Grafts
Pattern of coronary
grafting
Suggested
primary approach
LIMA
Left Radial
Documented facilitation compared to
femoral approach
LIMA + RIMA
Right Radial or
Femoral
Avoid contralateral cannulation in
severe atherosclerosis of the aortic
arch and subclavian arteries
LIMA + RIMA + RA
Femoral
LIMA + SVG(s)
Left Radial
SVG(s)
Right Radial or Left Left radial easier, specially during the
Radial
learning curve
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Comments
Consider aortography to visualize
SVGs and facilitate catheter selection
Burzotta F et al. CCI 2008;72:263-272
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Patients with coronary bypass grafts: Tips and tricks
• Judkins Right or
Multipurpose
• Amplatz Left, ULT1 or
Tiger (Judkins left or
Multipurpose from left
TRA)
• Amplatz left, Hockey
Stick, Extra backup
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Right TRA
Left TRA
Burzotta F et al. CCI 2008;72:263-272
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Challenges: Double Mammary Case
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Challenges: Double Mammary Case
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Challenges: Double Mammary Case
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Challenges: Double Mammary Case
VB-1
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Right IMA Angiography
Panel A: the IM catheter
cannot selectively engage
the right IMA because of its
sharp origin angle providing
suboptimal images.
Panel B: a more angulated
catheter, such as the IMVB1, can selectively
cannulate the right IMA
without difficulty providing
optimal angiographic
opacification of the vessel.
Catheter
Tip
A
B
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Considerations for Using 5F Guide Catheters
n=171
% of Patients
• Miniaturization of products
allow 5F use
• Small radial arteries may not
be suited for 6F guides
• Less spasm, less patient
discomfort
• Lower incidence of radial
vessel occlusion
• Less contrast/ injection = less
nephrotoxicity
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6
4
2
1.1
0
5 Fr
Proc Success
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5.9
Radial Artery Occlussion
95.4%
6 Fr
92.9%
Dahm J et al. CCI 2002; 57:172–176
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New Guiding Catheter Technologies
• Hydrophylic Sheathless Catheters
• - 7.5 Fr Catheter: OD < 6 Fr Sheath
• - 6.5 Fr Catheter: OD < 5 Fr Sheath
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Mamas MA et al, CCI 2008;72:357–364
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Sheathless Technique with Regular Catheters
A 5-Fr diagnostic catheter inserted into
and through a 7-Fr guiding catheter and
over a 0.035 inch standard J-tip
From AM, Gulati R, et al. CCI 2010; 76:911–916
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Conclusions
• Find the catheter that works best for you – Practice makes perfect
– Consider starting with Judkins and transition to single catheter technique once you feel more
confident.
• Guiding catheter engagement and support represent significant barriers to transradial
procedural success
– Keep the guidewire in the catheter until you cannulate
• Knowledge of guide catheter selection and technique enable successful PCI
• Complex PCI is achievable with existing equipment
– CTO, bifurcations, rotational atherectomy
• TR specific guiding catheters may offer advantages
• Dedicated sheathless guiding catheters now available in the US, but sheathless is possible with
standard equipment.
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THANK YOU!!
Mauricio Cohen
Cell: 305-873-4513
[email protected]
Carlos E Alfonso
Cell: 305-606-1988
[email protected]
CALL US (or any of the faculty)!!!
Share images, complications, advice
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