Guide catheters in coronary intervention
- 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 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
- 17. Guide co-axial Co-axial guide position is extremely important during procedure. Improves deliverability Reduces trauma and complications.
- 18. 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
- 19. 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
- 20. 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
- 21. Guide support
- 22. Guide size
- 23. Commonly used guide catheters • Judkins • Amplatz • Extra back up • Multipurpose guide
- 24. 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)
- 25. 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
- 26. Curve selection Curve selection depends on • Width of ascending aorta • Location of ostia • Orientation of vessel Proper curve essential for co-axial alignment.
- 27. 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
- 28. Amplatz guide • Commonly used – AL 0.75 and AL 1 • Size selection according to aortic size – larger aorta may requireAL 2 or AL 3. • Amplatz guide can cause significant aortic regurgitation. Main use in tortuous vessels or difficult lesions (calcified plaque)
- 29. 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
- 30. EBU (extra backup) guide • Commonly used size – EBU 3 / 3.5 (femoral) • 1st choice for LCA interventions
- 31. LCA interventions • Most common – EBU/XB • Left main disease/ostial lesion – Judkins left (JL) • Tortuous anatomy/very calcified lesions - Amplatz
- 32. 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
- 33. Special RCA catheters 3DRC (3 dimensional RCA catheter) Designed to cannulate RCA with minimal torque. Suitable for ostial lesions
- 34. Special RCA catheters ARANI • Double loop catheter (S configuration) • Contact with aorta at 2 sites – very good backup support • Useful in Shepherd crook RCA
- 35. Special RCA catheters Hockey stick • Meant for superior and horizontal take off of RCA • Higher support than JR
- 36. Extra Backup catheters for RCA
- 37. Trans-radial PCI Commonly used catheters – Left – EBU Right – JR, Amplatz Sizing – Downsize curve by 0.5 for radial procedures
- 38. 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
- 39. Ikari catheter
- 40. Ikari catheter Superior backup force Wider area of contact with aortic wall
- 41. Ikari catheter Ikari left can cannulate both LCA and RCA Available in 3 curves – 3.5,3.75 and 4
- 43. Extra backup inTR 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 • Sheathless techniques with hydrophilic large lumen guiding catheters (Eucath, ASAHI, Japan) • Hydrophilic-coated sheaths - reduce the force required to remove them and prevent the occurrence of spasm, improving patient comfort
- 50. PracticalTips- Radial vs Femoral
- 51. PracticalTips- Radial vs Femoral
- 52. PracticalTips- Sizing of catheters
- 53. PracticalTips- Sizing of catheters
- 54. PracticalTips- Sizing of catheters
- 55. JL 4 JL3.5
- 57. 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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