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 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.

58. THANKYOU