CORONARY ENGAGEMENT.pdf

CORONARY ENGAGEMENT
Dr. Thiều Minh Sơn, MD
Interventional Cardiology Fellow at
Khánh Hòa Provincial General Hospital
Nha Trang, May 28th 2023

CONTENTS
1. Anatomy of coronary ostium
2. Coronary engaging technique
3. Complications

01.
ANATOMY
Loukas, M., Sharma, A., Blaak, C. et al. The Clinical Anatomy of the Coronary Arteries. J. of Cardiovasc. Trans. Res. 6, 197–207 (2013). DOI: https://doi.org/10.1007/s12265-013-9452-5

J. of Cardiovasc. Trans. Res. 6, 197–207 (2013). DOI: https://doi.org/10.1007/s12265-013-9452-5
AORTIC ROOT
• The initial part of the ascending aorta
• Composed of:
• 3 semilunar leaflets
• 3 interleaflet triangles
• 3 sinuses of Valsalva
• Sinutubular junction (thickened area of the aortic
wall) separates the root from the ascending aorta.

J Thorac Cardiovasc Surg 2018;156:e41-74. DOI: https://doi.org/10.1016/j.jtcvs.2018.02.115

Clin. Cardiol. 15,451-457 (1992)
CORONARY OSTIA

Sakhuja, R., Gandhi, S. (2015). Diagnostic Coronary Angiography. DOI: 10.1007/978-3-642-37078-6_40.
LAO 30-50
Fig B: Aortic root in LAO projection (usual
projection for engaging the coronary arteries)
Fig A: Cross section of the heart through the
valve plane from above

Topol, E. J., & Teirstein, P. S. (2015). Textbook of interventional cardiology E-Book. Elsevier Health Sciences.
AP RAO 20 – CAU 20 LAO 40 – CAU 20
AORTIC ANGIOGRAPHY

Images Paediatr Cardiol. 2006 Apr;8(2):1-16.
LAO 45 PROJECTION

ANOMALOUS
ANATOMY

ECTOPIC
CORONARY
OSTIUM

SOLITARY
CORONARY
ARTERY
• Interarterial course
• Retroaortic course

02.
TECHNIQUE
• Step 1. Catheter selection
• Step 2. Advance guidewire to aortic root
• Step 3. Advance catheter to aortic root
• Step 4. Aspirate guide catheter
• Step 5. Connect with manifold
• Step 6. Check pressure waveform
• Step 7. Manipulate to engage coronary ostia
Brilakis, E. (2020). Manual of percutaneous coronary interventions: a step-by-step approach. Academic Press.

STEP 1. CATHETER SELECTION
Goal?
• Engage the target coronary artery easily and safely in
a co-axial orientation
• Providing optimal support.
Important?
• One of the most critical decisions to ensure
procedural success, efficiency, and safety.
How?
• Based on:
• Arterial access site (radial vs femoral)
• Target coronary vessel
• Size of the aorta

CATHETERS
ETYMOLOGY:
• “Catheter” is from Greek:
• kathe: to send down
• enai: to send
ROLES:
• Engage the coronary artery
 contrast injection 
coronary visualization
• Monitor pressure
• Deliver equipment (wires,
microcatheters, imaging
catheters, balloons,
stents,…)
Mason Sones (1918-1985) Melvin Judkins (1922-1985) Kurt Amplatz (1924-2019)

CATHETER
LENGTH
• Most catheters are 100 cm long
• Shorter catheters (usually 90
cm):
• Retrograde CTO PCI
• Deliver equipment to very
distal lesions (e.g., through
bypass grafts)
• Longer catheters (125 cm):
• Very tall patients
• Very tortuous aorta

SIDE HOLES
• PROS:
• Prevent pressure dampening
• Allow antegrade flow into the
vessel
• Prevent dissection during
contrast injection
• CONS:
• Provide a false sense of
security (dissections can still
occur upon injection)
• Higher contrast use & image
quality degradation
Side-hole guide catheters should not be engaged
to an unprotected LMCA (exception: ostial left
main CTOs), as suboptimal guide catheter
position may not be recognized  decreased
antegrade left main flow  global ischemia 
hemodynamic collapse

DIAGNOSTIC vs. GUIDING CATHETERS

CATHETER
SHAPES

HISTORY OF TRANSRADIAL CATHETERS
https://tis.terumo.com/products/radifocus_optitorque

GUIDE CATHETER SHAPES
Intervent Cardiol Clin 4 (2015) 145–159. DOI: http://dx.doi.org/10.1016/j.iccl.2014.12.001

TYPES
&
SIZES

JUDKINS CATHETERS

TIGER
CATHETERS
• Engage both LCA & RCA with
one catheter:
• Limit catheter exchange
• Shorten procedure &
flouroscopic time
• Lower cost
• Side holes:
• Avoid dissection & kicking-
off during injection in non
coaxial engagement

STEP 2. ADVANCING GUIDEWIRE
Goal?
• Advance a guidewire to the aortic root  rail for
advancing a catheter to the coronary ostia
How?
• Use a 0.035 or 0.038 inch J-tip guidewire
• Advance the guidewire together with the catheter
(over the arterial sheath)
• Guidewire tip should always stay ahead of the tip
of the catheter
• Under fluoroscopic guidance
• Advance guidewire to the aortic cusps  fix the
guidewire (usually by the assistant)  advance
the catheter over it

0.035-0.038” GUIDEWIRE
For tight lesions, tortuous vessels, or when entering a side branch or crossing an aneurysm  repeat
wiring attempts can be performed using various 0.035 - 0.038 inch guidewires (polymer jacketed or with
very soft tip)

0.014”
WIRE
Moscucci, M. (2013). Grossman & Baim's cardiac catheterization, angiography, and intervention. Lippincott Williams & Wilkins.
Navigating a radial loop using an 0.014 inch guidewire and then exchange for
an 0.035 inch guidewire
 The loop usually straightens as the 0.035 inch guidewire passes through or
with gentle pullback and counterclockwise torque of the entire system

STEP 3.
ADVANCE CATHETER
Goal?
• To advance the catheter to the aortic root,
next to the coronary ostia
How?
• Diagnostic catheters are flushed and
loaded over a 0.035 or 0.038” guidewire 
insert through the sheath
• Advance the catheter under fluoroscopic
guidance to the aortic root, while the
guidewire is fixed

Causes:
• Subintimal guidewire
position
• Severe stenosis
• Tortuosity
• Spasm
RESISTANCE TO
CATHETER
ADVANCEMENT

Diagnosis:
• Resistance to catheter advancement
• No arterial waveform
• No response to vasodilators
Solutions:
• Remove catheter and guidewire
• Change access site
• Check flow in the affected artery via contralateral
injection
Prevention:
• Do not force the guidewire or catheter
SUBINTIMAL GUIDEWIRE
POSITION

Femoral access:
• Use a different catheter with less tip angulation
• Advance a long sheath (45-55 cm) through the stenosis
 advance catheter
• Dilate the stenosis
• Occasionally required in severe iliac lesions
• Stents should be avoided prior to completion of
the PCI (they can be dislodged during catheter
advancement)
• Preexisting iliac stents  advance long sheath
through them (to minimize the risk of stent
deformation or dislodgement)
Radial access:
• Use a low profile sheath or a sheathless guide catheter
may gently dilate the stenosis without injuring the
vessel
SEVERE STENOSIS

Solutions:
• Use different guide catheter with less distal angulation
• Advance a long sheath through the area of tortuosity
• Parallel sheath technique for femoral access (perform
second puncture of the same femoral artery  insert a 4
Fr sheath  advance a stiff 0.035” guidewire to
straighten the iliac tortuosity)
• Balloon-assisted tracking (particularly for radial loops)
• Use a small compliant balloon (sized 1:1 with the
guide catheter)  inflated halfway in and halfway
out the tip of the guide catheter at low pressure (3-
6 atm)
• Lower pressure  more flexible
• Higher pressure  increases pushability
• Change access site.
TORTUOSITY

EuroIntervention 2014;10:231-235. DOI: 10.4244/EIJV10I2A37
PARALLEL SHEATH TECHNIQUE
A) Right iliac artery kinking despite 8 Fr - 45 cm
sheath and a 0.035” extra-stiff guidewire. A
diagnostic 5 Fr catheter was unable to be
advanced beyond the abdominal aorta because of
excessive friction.
B) A second long 5 Fr - 45 cm sheath parallel to the 8
Fr sheath and a stiff 0.035” guidewire via the 5 Fr
sheath straightened the artery. The angiography and
intervention were finished successfully without major
friction.

• Specific to radial access
• More common in women and smokers
Causes:
• Small radial artery size
• High origin radial artery
• Radial artery tortuosity
• Multiple needle passes to obtain access
• Extensive catheter manipulations
• Multiple catheter exchanges
• Inadequate sedation
Prevention:
• Avoid using small radial arteries (ultrasound guidance
while obtaining radial access)
• Vasodilator administration after sheath insertion
• Avoid using large catheters
• Adequate sedation prior to obtaining access.
SPASM
Spasm in a high origin radial artery

Cardiovascular Revascularization Medicine 14 (2013) 321–324. DOI: https://doi.org/10.1016/j.carrev.2013.08.009
Diagnosis:
• Resistance to catheter advancement
• ± arterial waveform
• Angiography (only when there is no arterial pressure
dampening)
Solutions:
• Administer intra-arterial vasodilators
• Subcutaneous nitroglycerin injection
• More sedation
• Use smaller guide catheters (such as 5 French)
• Use Heartrail (Terumo) guide catheters (with dimpled
surface that decreases friction)
• Use a sheathless guide catheter
• Use of hydrophilic sheaths and catheters
• Use of low profile sheaths for radial access.
SPASM

Causes:
• Very tall patients
• Severe subclavian or iliac/aortic
tortuosity
• Distal radial access
Solutions:
• Use longer catheters (may need
balloons and stents with long shaft)
• Use guide catheter extensions
• Parallel sheath technique (to straighten
the artery)
• Change access site (femoral route is
usually shorter)
FAILURE TO REACH THE
AORTIC ROOT

STEP 4.
ASPIRATE GUIDE CATHETER
Goal?
• To clear the catheter of any air or other
material (thrombus or plaque) before
engaging the coronary artery
How?
• Aspirated 2-3 mL of blood
• Discard over a white gauze to determine if
thrombus (usually from the sheath) or
plaque scraped from the aortic wall (often
has iridescent appearance due to
cholesterol crystals), has been retrieved
A
B
A: Thrombus. B: Plaque (debris scraped from
the aortic wall by coronary guiding catheters)

INABILITY TO
ASPIRATE BLOOD
A
B
Causes:
• Catheter tip:
• Against the aortic/
coronary wall
• Next to a ostial lesion
• Too large for the ostium
• Catheter is kinked
• Catheter contains plaque,
thrombus, air, etc
Warning: do not insert a guidewire and do not flush
the catheter if you cannot aspirate back, as this may
cause embolization of thrombus/plaque in the aorta,
potentially causing stroke or acute coronary occlusion.

STEP 5.
CONNECT WITH MANIFOLD
Goal?
• To connect the catheter with the
manifold, enabling pressure monitoring
and contrast injection
How?
• Connect the catheter hub with the
manifold
• Aspirate blood into the manifold syringe
• If there is any air or visible debris 
discard
• Inject contrast until it exits from the tip
of the guide catheter
A
B

STEP 6.
PRESSURE WAVEFORM
JACC: Cardiovascular Interventions 12.20 (2019): 2093-2101. DOI: https://doi.org/10.1016/j.jcin.2019.06.036
Goal?
• To ensure that:
• Catheter tip is free (in the aortic
root)
• Catheter lumen is clear of any
foreign material (thrombus,
plaque, air)
How?
• Inspect the pressure waveform:
• Damping?
• Ventricularization?
A
B

DAMPED
WAVEFORMS
J INVASIVE CARDIOL 2017;29(11):387-389.
A
B
“Damping” = overdamping
Characteristics:
• Abrupt decline of mean pressure
• Narrow pulse pressure
• Delayed upstroke and
downstroke
• Loss of dicrotic notch
Meaning:
• Severe partial obstruction
Figure 1: Pressure-wave damping. Note the abrupt decline of
coronary pressure with narrow pulse pressre and a delayed
upstroke and downstroke
Figure 2: Immediate pullback of the catheter  pressure
waveform returns back to baseline

DAMPED
WAVEFORMS
Causes?
• Catheter is:
• Against the aortic/coronary wall
• Deeply or subselectively
engaged
• Positioned next to a ostial lesion
• Too large
• Catheter contains plaque, thrombus,
air,…
• Catheter is kinked
• Pressure transducer malfunction
A
B

WARNING !!!
• Failure to recognize pressure
dampening followed by contrast
injection can cause potentially
catastrophic complications:
• Systemic embolization
• Coronary embolization
• Coronary dissection
• Aorto-coronary dissection
A
B

VENTRICULARIZED
WAVEFORMS
American Heart Journal, 01 Dec 1989, 118(6):1160-1166. DOI: 10.1016/0002-8703(89)90004-5
A
B
The term “ventricularization” is actually a
misnomer!
“Ventricularized” coronary pressure has no
etiologic relationship to the LV pressure!
Characteristics:
• Steep decline of diastolic pressure
• Decline of systolic pressure (to a lesser
extent)
• Large pulse pressure
• Absence of the dicrotic notch
• Presystolic positive deflection

CORONARY BLOOD FLOW
Alex Yartsev (2020). Coronary blood flow. Deranged Physiology.
A
B
• 5% of cardiac output
• 75% LM flow and 50% RCA flow occurs in diastole
• In systole, LV contraction  high chamber pressure 
blood flow is reduced
• RV systolic pressure is lower  blood flow is less affected
• In diastole, ventricular relaxation  sucks the blood (in the
aorta and the catheter) into coronary artery

VENTRICULARIZED
WAVEFORMS
American Heart Journal, 01 Dec 1989, 118(6):1160-1166. DOI: 10.1016/0002-8703(89)90004-5
A
B
Causes:
• Catheter is:
• Positioned next to a ostial lesion
• Too large
Mechanism:
• Very small residual space between the catheter
and the coronary artery  restricts the diastolic
blood flow into the coronary artery 
ventricular suction  steep decline of the
diastolic pressure
• Motion of the ascending aorta during atria
systole  presystolic positive deflection (easier
to identify because in these patients the
intracoronary pressure is flat at the time of this
wave)

VENTRICULARIZATION
Am Heart J. 1989 Dec;118(6):1160-6. doi: 10.1016/0002-8703(89)90004-5.
A
B
• Ventricularized pressure waveform can be considered a hybrid
between:
• Coronary arterial pressure, and
• Coronary wedge pressure
• Important clue to the presence of left main coronary artery
disease

VENTRICULARIZED WAVEFORMS
J INVASIVE CARDIOL 2017;29(11):387-389.
A
B
Significance:
• Continuing to inject contrast despite
ventricularization may lead to:
• Ventricular fibrillation
• Dissection of the proximal
coronary artery
Management:
• Withdraw the catheter and
reposition it, or
• Gently inject contrast while
withdrawing the catheter (hit and
run technique – experts only!)
• Spasm  nitroglycerin may help
Figure 1: Aortic (Ao) pressure from the coronary angiographic
catheter tip showing damping with “ventricularization”, which
requires quick injection and removal of the catheter, a “hit-and-
run” maneuver. To reduce the chances of a coronary dissection,
one should realign the catheter in a more coaxial position, if
possible.
The Cardiac Catheterization Handbook. 6th ed. Philadelphia, PA:
Elsevier; 2016: 137.

STEP 7.
ENGAGING CORONARY OSTIA
Goal?
• Insert the tip of the catheter into the
target coronary artery
• Optimal catheter engagement:
• No pressure dampening
• Coaxial orientation
• 2-3 mm engagement depth
A
B

JUDKINS LEFT (JL)
http://cardiaccathpro.com/LeftCoronaryAngio.html
A
B
• JL4 is the most commonly used
catheter for Left Coronary Angiography
• Pre-shaped to minimize the need for
manipulation
• The 4 reflects the length of the
segment between the primary and
secondary curve
• Patients with a small or narrow aortic
arch will usually need a JL3.5 catheter
• Catheter is too short  tip pointed
upward
• Catheter is too long  tip pointed
downward

JUDKINS LEFT (JL)
http://cardiaccathpro.com/LeftCoronaryAngio.html
A
B
• Advance JL catheter into the ascending aorta over a guidewire in the LAO view (30-50 degree)
 catheter tip positioned just below the coronary ostium
• Gentle pull back  catheter fall into the LM ostium  noted on screen by a sudden “dive” of
the catheter tip
• Slight rotation may be helpful (counterclockwise, as the left main ostium usually lies
posteriorly), but avoid excessive rotation

JUDKINS LEFT (JL)
A
B
• Advance the catheter tip 2-3 cm above the
upward deflection of the J wire
• Withdrawn the J wire  catheter tip fall
into the left cusp  then into the left main
ostium
• Advance the catheter tip too deep into
the right coronary cusp  prevents it
from entering the left coronary cusp

JUDKINS LEFT (JL)
A
B
1. Often, simply advancing the JL catheter without manipulation will
intubate the LM ostium
2. If the catheter tip lies below the coronary ostium despite gentle retraction
and torque  downsize (e.g., JL4 to JL3.5).
3. If the catheter folds on itself  upsize (e.g., JL4 to JL5).

JUDKINS RIGHT (JR)
A
B
• Advance the catheter is over a guidewire in the LAO view to the valve plane (the bottom
of the right coronary cusp)
• Slowly withdrawn from the valve plane 2–4 cm while simultaneously rotating clockwise
(anterior) approximately 180 degree

TIGER CATHETERS
A
B
Rotate counter-clockwise for LMCA Rotate clockwise for RCA

FAILURE TO
ENGAGE
A
B
Causes:
• Anomalous origin
• Ostial occlusion
• Peripheral tortuosity
 unable to
manipulate catheter
• Suboptimal catheter
size
• Suboptimal catheter
shape

PERIPHERAL TORTUOSITY
A
B
• Peripheral tortuosity  unable to manipulate catheter
Solutions:
• Insert a 0.035-0.038” guidewire  increase catheter stiffness  facilitating
manipulations + decreasing catheter kinking
• Insert the back end of a 0.035” guidewire (without exiting the catheter tip) 
straighten the catheter tip  easier to engage
• Insert a long (such as 45 cm) sheath  facilitating manipulations
• Use a catheter that slightly smaller than the sheath (e.g., 7F catheter - 8F sheath)
• Use a diagnostic catheter to engage  advance a 300 cm long 0.014” supportive
guidewire into the coronary artery  remove diagnostic catheter  insert guiding
catheter (diagnostic catheters have thicker walls  easier to manipulate)
• Spasm may hinder catheter manipulation (especially with radial access)  vasodilator
administration + use smaller catheters
• Change access site (e.g., radial  femoral)

03.
COMPLICATIONS
• PERIPHERAL ARTERY DISSECTION
• PERIPHERAL ARTERY PERFORATION
• VENTRICULAR ARRHYTHMIAS
• CATHETER KINKING
• SYSTEMIC EMBOLIZATION
• CORONARY EMBOLIZATION
• CORONARY DISSECTION
• AORTO-CORONARY DISSECTION

PERIPHERAL ARTERY
DISSECTION
Causes:
• Subintimal guidewire advancement
• Forceful sheath/catheter advancement
• Advance catheter without leading
guidewire
Diagnosis:
• Challenging catheter advancement 
angiography (only when there is no
arterial pressure dampening)

PERIPHERAL ARTERY DISSECTION
Treatment:
• Most often no specific treatment is required
• Small retrograde dissections are usually sealed off
by antegrade blood flow
• Large dissections may require endovascular repair
(usually with stent)
• Switch to different access site
Prevention:
• NEVER use force when advancing guidewires and
catheters
• Use long sheaths in patients with severe iliac
tortuosity
• Perform femoral angiography with a guidewire in
place (to keep the sheath tip away from the
arterial wall)

PERIPHERAL ARTERY
PERFORATION
Causes:
• Forceful guidewire or catheter
advancement into a side branch
• Small caliber artery
• Sheath advancement past the tip of the
guidewire
Diagnosis:
• Perform angiography when the guidewire
or catheter follows an unexpected course
or when resistance is felt during
advancement

PERIPHERAL
ARTERY
PERFORATION
Circ Cardiovasc Interv. 2019;12:e007386. DOI: 10.1161/CIRCINTERVENTIONS.119.007386
Radial artery:
• Advance a catheter over
the perforated segment 
usually suffices to achieve
hemostasis
Femoral artery:
• Balloon occlusion 
covered stent
Small branch:
• Coil (or fat or thrombus)
embolization

VENTRICULAR
ARRHYTHMIAS
Causes:
• Entry of the guidewire into the left ventricle
Solution:
• Remove guidewire from the left ventricle
Prevention:
• Monitor and adjust the position of the tip
of the guidewire to prevent entry into the
left ventricle

CATHETER
KINKING
A
B
Causes:
• Severe iliac/aortic/subclavian
tortuosity
• Extensive catheter
manipulation
Diagnosis:
• Catheter tip not moving
when rotating
• Dampened/lost pressure
waveform
• Fluoroscopy  confirm
kinking location

CATHETER KINKING
A
B
STEP 1:
• Gently untwist the catheter (opposite direction)  advance a 0.035” guidewire
through kinked segment (may use the guidewire back end)
• Kinking below the brachial artery (radial access)  inflate a blood pressure cuff at the
brachial artery to “fix” the kinked catheter  untwist  remove
STEP 2:
• Obtain another arterial access  snare the tip of the kinked catheter  straightening
the kinked segment  untwist
STEP 3:
• Attach an indeflator to the catheter hub  inflate to 3-4 atm
STEP 4:
• Cut the catheter hub  advance a sheath (same size or 1-2F larger than the catheter
size)  encase the kinked segment  withdrawal
STEP 5:
• Arteriotomy (pull knot through skin)

SYSTEMIC EMBOLIZATION
Circulation: Cardiovascular Interventions. 2019;12:e007791. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.119.007791
• One of the most feared complications
• Embolization material can be air, plaque,
thrombus
Causes:
• Not aspirate the guide catheter before
coronary artery engagement
• Plaque dislodgement (in patients with
significant aortic atherosclerosis) during
catheter advancement
Diagnosis:
• Depends on the area affected
• Stroke  acute neurologic deficit
• Lower extremity  pulses may decrease or
disappear, lower extremity discomfort
Major Complications With Diagnostic Left Heart Catheterization
(Study on 43.768 LHC procedures)

SYSTEMIC EMBOLIZATION
J Am Coll Cardiol 2018;71:1910–20. DOI: https://doi.org/10.1016/j.jacc.2018.02.065
Treatment:
• Stroke: emergency head CT + neurology
evaluation  may need emergent
neurointerventional treatment
• Other sites: usually conservative management,
sometimes endovascular treatment may be
required
Prevention:
• Aspirate and flush sheath before catheter
insertion
• Aspirate catheter before contrast injection
• Do not inject if there is dampening of the
pressure waveform
• Use a sheathless guide (with an inner dilator) 
prevents the “razor effect” and does not scrape
plaques

CORONARY EMBOLIZATION
Causes:
• Embolization material can be air,
thrombus (from catheters), or plaque
(from aortic plague dislodgement)
Diagnosis:
• Chest pain
• ST-segment elevation
• May develop cardiogenic shock or
cardiac arrest
• Angiography: decrease/cessation of
coronary flow

CORONARY EMBOLIZATION
Treatment:
• Air embolism:
• Administer 100% oxygen  helps absorb the
embolized air
• If antegrade flow stops  aspiration through guide
or thrombectomy catheter
• Repetitive forceful saline injections  “unclog”
vessels
• Intracoronary epinephrine (0.05 mg)
• Plaque/thrombus embolism:
• Anticoagulation and intravenous antiplatelet agents
(GP IIb/IIIa inhibitors or cangrelor)
• Thrombectomy (if large visible thrombus)
• Intracoronary vasodilators (nicardipine, nitroprusside,
verapamil, adenosine)

CORONARY DISSECTION
A. Lindsay et al. (2016). Complications of Percutaneous Coronary Intervention,DOI 10.1007/978-1-4471-4959-0_17
Causes:
• Non-coaxial catheter position
• Contrast injection despite pressure
dampening
• Ostial lesion
Diagnosis:
• Large dissections  impede coronary flow
 STEMI  possibly lead to cardiogenic
shock or cardiac arrest (especially LM
dissections)
• Small dissections may not (at least
immediately) impede coronary flow and
may be harder to detect.
• Angiography  filling defects
• IVUS, OCT may help confirm the diagnosis

CORONARY DISSECTION
American Heart Journal, Volume 159, Issue 6, 2010, Pages 1147-1153, ISSN 0002-8703, https://doi.org/10.1016/j.ahj.2010.03.012.
Treatment:
• Do NOT lose wire position (if a wire
is already within the target vessel)
• Small, non-flow limiting dissections
(A, B) usually not require
treatment
• Large dissections (C, D, E, F) 
stenting
• If dissection is caused by a
diagnostic catheter  insert a
guidewire (through the diagnostic
catheter) into the true lumen (if
feasible)  obtain a second arterial
access  engage the coronary
artery with another guide catheter
(“ping pong” technique)
Examples and relative incidence (percentage) of types of iatrogenic LM dissection

AORTO-
CORONARY
DISSECTION
American Heart Journal, Volume 159, Issue 6, 2010, Pages 1147-1153, ISSN 0002-8703, https://doi.org/10.1016/j.ahj.2010.03.012.
Causes:
• Noncoaxial catheter position
• Ostial lesion
• Contrast injection despite pressure
dampening
Diagnosis:
• Contrast “staining” within the aortic
wall
Treatment:
• Do NOT inject
• Stent the coronary artery ostium 
seal off the contrast entry point
• If standard stents fail  covered stent Examples, relative incidence, and outcome of iatrogenic LM dissection

J Thorac Cardiovasc Surg 2006;131:230-10022-5223. DOi:10.1016/j.jtcvs.2005.08.051
Fig 1. Proximal aortic dissection, with contrast
clearly seen filling the false lumen on both sides of
the aortic wall (arrows)
Fig 2. Coronary dissection at the RCA ostium (white
arrow), with retrograde contrast seen in the aortic wall
(black arrow).

Baumann et al. BMC Medical Imaging (2017) 17:64. DOI:10.1186/s12880-017-0227-3

CONCLUSIONS
1. Engaging the coronary artery ostia is one of the most essential steps of
diagnostic angiography and PCI
2. Using multiple catheters (Judkins, Amplatz) or single catheter (Tiger, Jacky)
3. Requirements of an optimal catheter engagement: no pressure dampening,
coaxial orientation, 2-3 mm engagement depth
4. Pressure waveform monitor is of the utmost importance. Failure to recognize
pressure damping/ventricularization followed by contrast injection can cause
catastrophic complications.

FINAL MESSAGE
“Never take your eyes off the monitor and the pressure curve!”
“Serious complications in the cath lab often happen not out of
ignorance or lack of expertise, but because of ignoring some
basic principles and lack of cath lab discipline.”

CORONARY ENGAGEMENT.pdf

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CORONARY ENGAGEMENT.pdf