This document discusses selecting guiding catheters for percutaneous coronary interventions (PCI). It provides guidance on catheter selection for different coronary arteries and bypass grafts. Key points include using stiffer, larger guides for support; deep intubation and guide extensions; and balloon anchoring or buddy wires. Techniques like keeping a wire in the catheter during engagement and using the wire backend to modify shape are reviewed. Standard guides can be used for complex PCI like CTO and bifurcations when combined with techniques for support. Maintaining guidewire backup in the catheter is important for successful transradial procedures.

1. Select Guiding Catheter
Mauricio G. Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Associate Professor of Medicine
@DrMauricioCohen

2. Disclosure Statement of Financial Interest
I have no financial conflicts of interest related to this presentation

4. Failure Modes for TR PCI
13
34
10
6
1
18 17
0
10
20
30
40
Inadequate
arterial
puncture
Radial Spasm Radial
Dissection
Tortuosity/Loop Radial
Stenosis
Subclavian
Tortuosity
Inadequate
guide backup
Patients,%
Failure of Arterial
Access
Failure to Advance
the Catheter to the
Aorta
Failure to Complete
PCI due to Lack of
Guide Support
Dehghani P, et al. JACC Cardiovasc Interv. 2009;2:1057-1064
N=2,100 – Failure 97 pts (4.7%)
35%

5. Ideal Guiding Catheter
• Safe, soft tip, low risk of dissection
• Easy to engage and manipulate
• Coaxial engagement
• Backup support
• Stable

6. Techniques to Improve Support
• Selection of stiffer, larger guide
• Deep intubation  Active support
• Guide extensions
 Guideliner, Guidezilla
• Balloon Anchoring
• Buddy wire
 Stiff wire in LCx while working on LAD

7. Femoral and Radial Are Different

8. Guiding Catheters and Device Compatibility
Catheter Device Kissing
balloon
Kissing
Stents
5F Balloon ≤ 5 mm No No
Stent ≤ 4.5 mm
Intravascular ultrasound
Rotational atherectomy (1.25 mm burr)
6F All balloon sizes Yes No
All stent sizes
Intravascular ultrasound / OCT
Graftmaster 2.8-4.0 mm
Rotational atherectomy (1.5 and 1.75 mm burr)
Aspiration thrombectomy catheters
Embolic protection devices for SVG interventions
Catheter extensions (Mother-Child / GuideLiner)
7F Rotational atherectomy (> 1.75 mm burr) Yes Yes
Bertrand OF and Rao SV, eds. Best Practice in Transradial Angiography and
Interventions. Philadelphia, Lippincott Williams & Wilkins; 2014:79-96.

9. Most Commonly Used Left Guide
Catheters

10. Catheter selection - Radial vs. Femoral
Radial
Femoral
Ikari Y, et. al. J Invasive Cardiol. 2005;17:636-641
Radial
Femoral
Hinge

11. Most Commonly Used Right Guide
Catheters

12. Backup Force in the RCA
JR IR AL IL
0
20
40
60
80
100
120
140
160
JR4 IR1.5 AL1 IL3.5
maxresistance(gforce)
C DA B
Ikari Y et al. J Invasive Cardiol. 2009;21:570-574

13. Guide Catheter Preference for Native
Coronary Arteries during TRA
Coronary Interventions
46.2
22.5
8.1 6.5
16.7
0
10
20
30
40
50
60
70
80
XB/EBU
3.5
JudkinsL
XB3.0
EBU3.75
Other
%ofoperators
70.2
10.2
5.8
13.8
JudkinsR
AmplatzR
AmplatzL
Other
Left Anterior Descending
Left Circumflex
Right Coronary 61.4
12.5 10.8
14.8
EBU/XB
JudkinsL
AmplatzL
Other
Bertrand OF et al. JACC Interv. 2010;3:1022-1031

14. Most Commonly Used Guiding Catheter Shapes For The Left And Right Coronary Arteries
Extra Backup
(XB – EBU -
Voda)
Judkins
Right

15. Keep the 0.035” Wire in the
Guiding Catheter while Engaging
Patel T et al. J Invasive Cardiol. 2011 May;23(5):E126-7

16. Deep Intubation RCA with JR4
Active Support

17. Using the Stiff Backend of the Wire to Facilitate Engagement

18. Using Standard Guides For Both Coronaries
Case: Anterior STEMI

19. Using the Stiff Backend of the Wire to
Modify Catheter Shape

21. Balloon Anchoring Technique
Guideliner + Anchor Balloon
3.5x10 mm Euphora balloon

22. Distal Stenting

23. 3.5x22 Resolute DES

24. Using JL 3.5 as Universal Catheter

25. Using JL 3.5 as Universal Catheter

26. Pattern of coronary
grafting
Suggested
primary
approach
Comments
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
Consider aortography to visualize
SVGs and facilitate catheter
selection
SVG(s)
Right Radial or Left
Radial
Left radial easier, specially during
the learning curve
TRA in Patients with Grafts
Burzotta F et al. CCI 2008;72:263-272

27. Judkins Right or Multipurpose
Amplatz Left or Tiger (Judkins left or Multipurpose from left TRA)
Amplatz left, Hockey Stick, Extra backup
Right
TRA
Left
TRA
Burzotta F et al. CCI 2008;72:263-272
Coronary bypass grafts

28. Guide Catheter Preference for
Engagement of SVGs
37.3
31
19.4
6.2 6
0
10
20
30
40
50 AmplatzL
JudkinsR
LCB
Multipurpose
Other
%ofoperators
39.6
29.2
20.8
3.5
6.9
JudkinsR
Multipurpos
e
AmplatzL
LCB
Other
Right SVG
Left SVG
Bertrand OF et al. JACC Interv. 2010;3:1022-1031

29. RIMA
angiography
IM catheter cannot
selectively engage the right
IMA because of its sharp
origin angle providing
suboptimal images.
A more angulated catheter,
such as the IM-VB1, can
selectively cannulate the
right IMA without difficulty
providing optimal
angiographic opacification
of the vessel.
B
A
Catheter Tip
VB-1

30. Use of VB1 Catheter for RIMA
Engagement

31. Double Mammary

32. Graft Case

33. SVG to OM
6F AL 1 Guide

34. 3.5x18 mm Resolute stents
in ostium and body

35. LAD CTO Distal to LIMA Insertion

36. Use of Guideliner for Better Support

38. Conclusions
• Guiding catheter engagement and support
represent significant barriers to transradial
procedural success
 Keep the 0.035” guidewire in the catheter until you
cannulate
• Knowledge of guide catheter selection,
physics, and technique enables successful
PCI
 Use the catheter you like best and works for you
• Complex PCI is achievable with standard
guiding catheters
 CTO, bifurcations, rotational ablation
• More coming in the next lectures