Overview of diagnostic catheters used in coronary angiography Guide catheters not included History of coronary catheters Radial techniques and catheters

1. DIAGNOSTIC
CATHETERS-
CORONARY
ASWIN R.M.
1

2. History
Classification
Catheter structure & Materials
Femoral Catheters
Radial Catheters
Cathetrs for IMA & graft
2

3. FIRST CARDIAC
CATHETERISATION
■ In 1929
■ Werner Forssmann
■ Rubber catheter
■ Through his own antecubital
Vein
■ Upto the pulmonary artery
3

4. HISTORY OF CORONARY
CATHETERIZATION
Selective cannulation of coronory or injection of
dye into coronary arteries were considered unsafe
■ Random "Brute Force" Approach – Upto 50 cc contrast in
1-2 sec
■ Phasic injections – electronic pressure injectors timed
with cardiac cycle for intentional diastolic injection
■ Methods of reducing cardiac output
– Acetylcholine arrest
– Elevation of intrabronchial pressure
■ Occlusion aortography
■ Differential opacification of aortic stream
4

5. FIRST SELECTIVE CORONARY
ANGIOGRAM
■ Was an accident
■ Dr Mason Sones in 1958
■ After withdrawing a catheter
after ventriculogram cannulated
the RCA unknowingly
■ When contrast was injected for
an aortogram selective
opacification of RCA noted
■ Designed Sones catheter and
popularized the technique
■ Several preformed catheters
were later designed.
5

6. DIAGNOSTIC CATHETERS
Angiography
Pressure monitoring
Oxygen saturation monitoring
6

7. ANGIOGRAPHIC CATHETERS
Flush
• No selective canulation of
vessel
• Contrast injection through
multiple side holes
• Uniform injection without recoil
• Tip usually rounded to avoid
entering a vessel and to keep
shaft in centre
• Ex Pigtal catheter
Selective
• Selectively canulation of vessel
• Rotational stiffness enough to
selectively seek a vessel orifice
• Enough flexibility to advance
into the vessel
• Flow rate not important as
contrast volume used is less.
• Ex – preformed coronary
catheters
7

8. CORONARY CATHETERS
Diagnostic
• Thicker shaft
• Internal dm
Smaller
• Tapering tip
• Less Reinforced
construction ( 2
layers)
Guide
• Thinner shaft
• Internal dm
larger
• Non tapering tip
• More Reinforced
construction ( 3
layers)
8

9. IDEAL CHARACTERISTICS OF
A CATHETER
■ Better Torque Control
– Increase Outer diameter
– Reinforced construction
■ Pushability
– Increase Outer diameter
– Stiffer Material
– Decreasing overall part length
■ Flexibility
– Decrease Outer diameter
– Material with less modulus of elasticity
– Increasing overall part length
■ Trackability
■ Radio-opacity
■ Atraumatic Tip
■ Low Surface frictional resistance
■ Kink resistance
9

10. PARTS
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A) TIP LENGTH – Increased length offers more
stability in target vessel at the cost of
maneuverability in the parent vessel.
B) PRIMARY CURVE – angle of the target vessel
from its parent artery.
C) SECONDARY CURVE -- width of the parent
vessel.
D) TERTIARY CURVE –normal curvature of the
parent vessel.
E) CATHETER LENGTH – Usually 100 or 110 cm

11. Over bent & Under bent
catheters
Underbent-
Angle of catheter tip is larger
outside the body than inside
■ Difficult to manipulate, shape
difficult to predict
■ Difficult to do deep engagement
Over bent-
Angle of catheter tip is smaller outside
the body, than inside
■ Shape of overbent inside body-easy to
predict
■ Easier to manipulate
11

12. SIZE MEASUREMENT:
FRENCH CATHETER SCALE:
The French catheter scale is commonly used to measure the
outer diameter of cylindrical medical instruments
D(mm) = Fr/3
Most commonly in adults -- Diagnostic Catheters of 5 – 7 Fr
size
12

13. ■ Thick walled-
– Better pushability and torque transmission
– Accentuates pressure waveform-systolic
overshoot & diastolic dips.
■ Thin walled _
– Improves monitoring, blood sampling & flushing
abilities, decrease thrombogenicity.
– Disadvantage – less torque control, not suitable
for high pressure injection.
WALL THICKNESS
13

14. 14
CATHETER MATERIALS
Angiographic catheters made from Synthetic and
semisynthetic Polymers
Dacron
Nylon
Polyvinylchloride (PVC)
Polyethylene (PE)
Fluoropolymers (PTFE) (TEFLON)
Polyurethane (PUR)
Silicon
Radio opacity by incorporating Ba , Bi , Ir

15. CHARACTERISTICS
Flexibility & Stiffness (Elastic coefficient)
Friction coefficient – Vascular Trauma
Thrombogenicity
Tensile Strength (Memory)
Moisture & Drug absorption
Mouldabilty
15

16. ■ Very maneuverable & flexible.
■ Covered by polyurethane coating – reduce vascular
trauma.
■ Some have Nylon core-increase bursting pressure
■ Nylon – great mechanical & physical strength,
reduced friction coefficient – achieve high flow rate
of fluids
■ Eg- NIH Catheter , Original Sones Catheter.
DACRON
16

17. ■ Excellent memory
■ Softer than polyethylene or Teflon – Less vascular
trauma
■ Increased thrombogenicity
■ Reshaped if immersed in boling water.
■ Eg – pigtail angiographic (cordis) catheters & original
judkins catheters.
POLYURETHANE
17

18. ■ Stiffness inbetween Polyurethane & Teflon.
■ More Thrombogenic than PVC, polyurethane
■ Heat Mouldablity good
■ Eg – pigtail angiographic catheters, judkins
catheters
POLYETHYLENE
18

19. ■ Softest & flexible among all
■ High friction coefficient- spasm.
■ Increased thrombogenicity.
■ Very poor tensile strength (memory)
■ Cant be reformed.
■ Most hydrophilic.
■ Drugs absorbed- NTG, insulin,
diazepam,thiopentone.
■ Eg- Balloon-tip flow directed catheters.
POLYVINYL CHLORIDE
19

20. ■ Stiffest – no suitable for selective catheters
■ Poor memory.
■ Low friction coefficient.
■ Eg – Brockenbrough catheters, transducer-tip
catheters & introducer sheaths.
TEFLON
20

21. CATHETER LAYERS
21
Outer Layer
Reinforcement –usually
stainless steel braid
Determines torque and Kink
resistance
Outer coating to reduce
friction and thrombogenisity

22. ■ TIP: Tapering tip for
Diagnostic catheters
■ HUB: Metal or plastic, larger
than catheter, tapered hubs –
easier insertion of guidewire.
TIP & HUB
22

23. SIDE HOLES
Advantages
 Prevent catheter damping (occlusion of the coronary
ostium)
 Allow additional blood flow out of tip, to perfuse the
artery.
 Avoid catastrophic dissections in the ostium of the
artery
 Avoids Disengagement during Injections
Disadvantages
 False sense of security because now, aortic pressure,
and not the coronary pressure is being monitored.
 Suboptimal opacification
 Makes catheter tip weak - kinking at side holes
23

24. Catheter Choices
24
Left Catheters
•Judkins Left
•Amplatz Left
Right Catheters
•Judkins Right
•Amplatz Right
•Right Coronary
3D
Universal
•Multipurpose
•Sones
•Castillo
Universal Radial
•Tiger
•Jackey
•Kimney
•Etc..
Graft & IMA
Catheters
•RCB
•LCB
•IMA
•IMA VB-1

25. Catheter choice and size
selection
Catheter
Choice
Access
Height &
weight
Age
Anatomy
of aorta
Target
vessel
Native
coronory
/ post
CABG
ACS vs
Elective
Operator
25

26. Catheters for
Native coronaries
26

27. JUDKINS CATHETER
■ Melvin Judkins in 1967
■ Preformed catheter
■ Primary and secondary curve
■ Tapered tip with end hole
■ Designed for femoral route
■ Little manipulation needed if
used from femoral route
27

28. JUDKINS CATHETER
 Size 3.5to 6 by most
companies
 Length 100 cm
 4-7 French available
 Size 4 usually used
 Right radial access
 0.5 less size used for
left Coronary
 1 larger size for right
Coronary
 In aortic aneurysms heat
modification for size 7 to
10 done
Curve length = distance between P
(primary curve) & S (secondary curve)
28

29. ENGAGEMENT
■ Left Judkins
■ Right Judkins
29

30. 30

31. Aortic width
31

32. AMPLATZ CATHETER
■ Original catheter by Kurt Amplatz
■ Austrian Radiologist
■ 1967
■ Right and Left comes in 3 sizes
usually
■ 1 ,2,3 with increasing curvature
■ 0.75 size , increments of .5 and 4
size also available for AL
32

33. AMPLATZ LEFT
■ Coronory ostia out of conventional judkins
Like high and posterior origin
■ It can selectively canulate LAD or LCX if short
left main stem
■ Separate origins of left anterior descending
and left circumflex coronary arteries.
■ High anterior right coronary arteries (RCAs) or
Shepherd’s Crook RCA.
33
While engaging the left coronary pushing the catheter will cause
disengagement and pulling the catheter will cause deeper engagement of
the Amplatz catheter, due to its peculiar curve

34. AMPLATZ RIGHT
■ Amplatz right coronary catheter can be
used to cannulate right coronary arteries
with abnormal, usually, an inferior origin
or high anterior
34

35. Coronary anatomy Variation
Coronary ostial location:
 High
 Low
 Anterior
 Posterior
Coronary ostial orientation (take offs):
 Superior
 Horizontal
 Inferior
 Shepherd’s crook (RCA’s only)
35

36. Coronary Ostial take offs
Horizontal Inferior Superior Shepard crook
RCA
36

37. SUMMARY
RCA
Normal origin And Course JR4
Anterior ectopic origin AR, AL , Hockey stick
Inferior ectopic origin with inferior course MP
Superior ectopic origin from ascending
thoracic aorta with inferior course
MP
Superior course IM 3DRC
Tortuous bend anatomy , posterior takeoff 3DRC
Anomalous RCA from left sinus JL 5,6 AR 2,3,
LMCA
Normal origin and course Jl4
Large ascending thoracic aorta JL 5,6
Small Acsending thoracic aorta JL3 , 3.5
Anomolous origin from right sinus AR
Anomolous origin of LCX from right sinus JR AR MP
Separate origin of LCX LAD AR
37

38. MULTIPURPOSE CATHETER
■ Initial multipurpose catheter by
Schoonmaker & King
■ In 1974
■ Developed to avoid the need of 3
separate preformed catheters for
both coronaries and ventriculography
from femoral route
■ Similar to the Sones catheter
■ Polyurethane catheter
■ Single curve with straight tip an end
hole and two side holes.
38

39. MULTIPURPOSE CATHETER
■ A bend – hockey stick with straight tip 120 degree curve
■ B bend -- gradual 90 degree curve
■ MP A-1 : 1 end hole only
MP A-2 : 2side holes ,1end hole
MP B-1 : 1 end hole only
MP B-2: 2 sideholes and an end hole
■ Use: CAG – Both native vessel and graft , Ventriculography , Right heart
catheterization
■ With more specialized catheters its use has decreased
39

40. Other Catheters
3DRC Castillo
Gensini Sones
40

41. RADIAL ACCESS
More learning curve
More radiation to operator
Limits guide catheter size
41
Less bleeding and vascular complications
Cost effective
Patients preference
Early discharge
Anticoagulants can be continued

42. RADIAL ACCESS
Standard catheters are all designed to to be used
from femoral route
High learning curve
High Incidence of artery going for spam – hence
catheter exchanges should be minimized
Subclavian tortuosities, Radial loops, Anomolous
High origin of radial artery
Sheath and catheter size limitaiton
42

43. RADIAL ACCESS
■ Course of catheter
43

44. Difficulty passing to aorta
44

45. DIAGNOSTIC CATHETERS -
RADIAL APPROACH
■ Two catheter
– JR & JL
– AR & AL
■ Single Catheter
– Standard femoral catheters – JL , AL , AR
– Universal /Bilateral catheters – Ex:
■ Tiger , Jacky , Sarah (Terumo)
■ Kimney (Boston Scientific)
■ MAC 30-30 ( Medtronic)
■ Ultimate Radial 1 & 2 (Merit medical)
■ Bilateral Brachial (Cordis)
45

46. Coronary Speciifc or Universal
??
46
Advantages
• No exchange
• Less flouro time
Disadvantages
• Learning curve
• Coaxial engagement
difficult – Increased
ostial trauma
• Inferior take offs –
deep seating
• Inferior take off RCA –
S elective Conus
branch canulation

47. Tiger & Jacky Catheter
■ Both RCA and LCA with one catheter that can
potentially:
– Limit catheter exchanges
– Shorten procedure and fluoroscopic time
– Lower cost per procedure
■ Side hole
– Avoids intimal dissection during injection
in non coaxial engagement
– prevents Kicking off during injections and
■ Available in 5F & 6 F
■ Nowadays used for transradial diagnostics
more than any other catheter
47

48. 1 side hole
Size 4 & 4.5
Length 100 & 110 cm
Rarley Coaxial
Selective canulation of conus
branch can occur
2 side holes
Size 3.5 & 4 (Sarah)
Length 100 & 110 cm
Amplatz type tip
Better canulation
Ventriculography
48

49. HEIGHT
■ Very tall patients 100 cm
catheters cannot reach upto
coronary ostia
■ Solution
– 110 cm Diagnostic
catheters
– Multipupose catheter
with 125 cm
– If radial prefer Left
Radial access
– High radial puncture
49

50. WEIGHT
■ Obesity
– Diaphragm moves cephalad
– Heart axis horizontal
– Short ascending aorta
– Counter clockwise rotation of coronary ostia
– RCA more anterior and LMCA more posterior
take off
– If radial Left Radial has advantage over right
50

51. POST CABG
■ Vessels to tackle LIMA RIMA Grafts (ReSVG or
Arterial)
51

52. SVG or ARTERIAL GRAFTS
■ Usually Anterior surface higher up
from sinus of vasalva
■ Left coronary grafts - left anterior
surface with circumflex grafts higher
up
■ Right coronary grafts -right anterior
surface
■ Ring markers often placed otherwise
have to rely on surgeons report and
previous angios
■ JR catheter mainstay in graft angios
52
■ A – dRCA / dLCX ( in L dominant
systems)
■ B- LAD
■ C- Diagonal
■ D- LCX / OM / Ramus

53. Catheter selection
■ Right Grafts
– Primary choice - MP
– Alternative – JR , RCB , AL
■ Left Grafts :
– Primary Choice – JR4 , AL1
– Upward trajectory may require - LCB , IM , HS
– More anterior origin – AL , HS > JR , LCB , MP
53

54. BYPASS CATHETERS
■ RCB
– Resembles JR4 with a tip curved >90
degree
■ LCB
– Primary curve similar to JR4 ( 90 degree )
but secondary curve more acute ( 70
degree)
54

55. POST CABG
LIMA & RIMA
 Normal – IM , JR4
 Origin from vertical portion
of subclavian artery- JR4 ,
 If radial - left radial approach
is more suitable in patients
with LIMA graft
 If Both LIMA and RIMA is to
be canulated JR4 – can avoid
catheter exchange
55
IM
LCB

56. Internal mammary catheter
■ Resembles Judkins right except for
tighter primary curve (80degree) and
longer tip
56
IMVB-1

57. Other Catheters for IMA
■ BARBEAU
■ RIMA
57

58. LIMA CANULATION
■ Ease = Femoral = LRA>>RRA
■ Techniques for LIMA cannulation with IMA catheters from RRA
are described
■ All of them based on passing a guide wire upto left elbow and
catheter passed over wire
58

59. LIMA CANULATION
■ Special Catheters for RRA LIMA also
designed
■ Ex: Yumiko Catheter
59

60. Right Gastroepiploic
■ Usually to PDA
■ Visceral angiographic catheter
like cobra can be used
■ Alternatively JR IMA
■ For angiography non selective
injection of coeliac trunk done
60

61. SUMMARY
Burzotta F et al. CCI 2008;72:263-272
61
Pattern of Coronary
Grafting
Suggested primary
approach
LIMA LRA
LIMA + RIMA RRA or Femoral
LIMA + RIMA + RA Femoral
LIMA + ReSVG(s) LRA
ReSVG(s RRA or LRA

62. THANK YOU
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