GC Conference

Guiding Catheters
Masoud Sajjadi
Fellowship of Interventional Cardiology
Mashhad University of Medical Sciences
Mashhad, Iran
June 2018

Guiding Catheter
Function
&
Structure

Guiding Catheter Function
• 3 Major GC Functions During PCI
• 1. Balloon/Stent Catheter Delivery
• 2. Backup Support for Balloon/stent advancement
• 3. Coronary Pressure Monitoring and Contrast Injections
Morton Kern . 2018

Guiding Catheter Structure
Outer Layer : Polyurethane or Polyethylene and is Responsible for Overall Stiffness,
Support, Curve retention
Middle Layer : Stainless Steel Responsible for Torque Generation
Inner Layer : Composed of Teflon for Smooth Passage of Balloons, Stents, and Devices
Euro PCR Book . 2014 CV Catheterization and Intervention 2018

Guiding Catheter Size
• Most Procedures In Current Practice can be Completed by
6F GCs ( Grossman 2014 ) Associated with Fewer Femoral
Vascular Complications than Larger Ones
• 7 Fr: Two-Stent Strategy for Bifurcation Lesions,
Rotational atherectomy Burr of 2 mm
• 8 Fr : Rotational atherectomy Burr of 2.15 or 2.25 mm
• Use of 6F (or In Some Patients 7F) GC s with TRA Most
Routine PCI Because with markedly Reduced Vascular
Complications
Practical Manual of Interventional Cardiology . 2014

Guiding Catheter Size
Euro – PCR Book 2014

Guiding Catheter Length
• The Standard Length of a PCI GC is 100 cm
• Shorter (80–90 cm) GC are useful for PCI of
1. Distal Lesions ( Long SVG or LIMA to LAD )
2. CTO PCI Using the Retrograde Approach
Other Methods to Use :
A. Extra-long Balloon Catheters ( e.g., 148 cm Ryujin® Plus; Terumo Corp )
B. GC can be Shortened and Capped with a Flared, Short Sheath
One size Smaller
Euro-PCR 2014

Guiding Catheter vs Diagnostic Catheter
1. GCs : Thinner walls, Larger Lumens, and Stiffer Shafts
Current GC Lumen Diameter is at Least Twice of
Diagnostic Catheter ( Grossman 2014 )
Morton Kern . 2018Tips and Tricks In Interventional Cardiology . 2014

Guiding Catheter vs Diagnostic Catheter
2. GC have Less Torque Control and More Kinking
3. Tapered Tip with Tighter Primary Curve In Diagnostic
Catheter vs Non-Tapered Shorter and Less Angulated
Tip with More Open Primary Curve In GC
4. Pressure wave Damping is seen more Often than with
Similar-Size Diagnostic Angiographic Catheters
Morton Kern . 2018Tips and Tricks In Interventional Cardiology . 2014

• Passive Support is the Strong Support Given by the Inherent
Design of GC and its Interaction with the walls of the Aortic Root
• Passive Support can be Increased by Increasing the Caliber of the
GC and by Selecting a Shape that Provides Greater Contact with
the Contralateral Aortic wall,
• Minimal Manipulation of the GC is Required
• Active Support is achieved by either Manipulation of the GC or
Subselective Intubation with Deep Engagement of the GC to
Maximize Backup Support
Active vs Passive Support
Practical Handbook of Advanced Interventional Cardiology Tips and Tricks . 2014
CV Catheterization and Intervention 2018

• Some GCs , Such as
1. Vista Brite ( Cordis Corporation ),
2. Launcher ( Medtronic )
3. Runway ( Boston Scientific )
are Better Suited to Provide Passive Support

STANDARD SAFETY TECHNIQUES
Practical Handbook of Advanced Interventional Cardiology
Tips and Tricks . 2014

A. Diastolic Pressure ( Ventricularization ), Most common cause of
Ventricularization is Ostial Lesion
B. Both systolic and Diastolic Pressure ( Dampened Pressure )
Dampening of Arterial Pressure

Causes
1. Significant Lesion in the Ostium
2. Coronary spasm
3. Non-Coaxial Alignment of the GC
4. Mismatch Between the Diameter of the GC and the arterial Lumen
This is True for 7Fr GC if the artery is Small or there is Plaque at the
Ostium. It can Cause Periprocedural Ischemia

Dampening Pressure Due to LM lesion
 Gradual Repositioning and Withdrawal of the Catheter Eliminate
Pressure Dampening
 Injection of Contrast Agent in Case of Dampening of Pressure,
Even a Small Amount, Can Further Lift the Plaque and Really
Cause a Dissection that can Become Disastrous

• Dampening Caused by a Small Coronary Artery, GC can be
Exchanged to One with Side Holes, which Allows Passive Blood Flow
into the Distal Coronary Artery ( Maintain Coronary Perfusion )
1. Suboptimal Opacification of the artery and Increased Contrast
Volume
2. Decreased Backup support due to weakened GC shaft
3. Kinking of the GC at the sideholes, if the GC is Excessively
Manipulated
4. False Sense of Security by Showing Normal Pressure Tracing in the
Face of Reduced Coronary Perfusion ( Grossman 2014 )
Side Hole GC

• GC with side holes could be used ideally in PCI of CTOs of the RCA
with Antegrade collaterals. This Generally Guarantees Antegrade
Flow Even During Deep GC Intubation, which Permits Distal
Opacification During Contrast Injections, thus avoiding possible
Ischemia
• Side hole GC may Result in Overestimation of FFR, Not Suitable for
Hemodynamic Lesion Assessment
Side Hole GC

• Gently advance and retract the GCas needed, Ensuring Proper
Stent Position and Contrast Opacification
• Almost all Interventional Devices are Rigid and of Large Profile,
Non-Coaxial Alignmentof the GC may lead to injury, Endothelial
denudation Causing Thrombus or Dissection of the Ostium of the
Coronary Vessel
Coaxial Guide Alignment

While the GC is still Engaging the artery with a wire across the lesion
1. GC should be Clamped by a Hemostat to Prevent Blood Loss During
the Shortening Procedure
2. Care must be taken that the Scalpel does Not Damage the Wire
Shortening GC

Shortening GC (First Technique)

Shortening GC (Second Technique)

• Most Commonly Used GC :
1. Judkins
2. Amplatz
3. Extra Backup GC
EBU from Medtronic ,
XB from Cordis ,
SBS from Merit ,
GC Types

• MP GC
A. RCA Graft
B. High LM takeoff
C. Downward takeoff RCA
• LIMA GC
A. LIMA to LAD
B. Superiorly Oriented Graft
C. Upward takeoff RCA
GC Types

From the Design Standpoint, catheters can be classified into two
groups:
1. Distal Curves that are “Overbent” (e.g., Judkins, Voda, Q-Curve,
Extra Back-Up, XB)
2. those that are “Underbent” (e.g., Amplatz and MP )
• The Overbent Catheters Generally have Good and Predictable
Response
• Underbent Catheters are more Difficult to Manipulate, and may be
associated with Higher Risks During Catheter Manipulation
GC Types
Euro PCR Book. 2014

Types of GC for Support :
– Left : EBU/XB > VL > JL
– Right : AL > AR/IM > JR
GC Support
Practical Manual of Interventional Cardiology . 2014

JL Size

Judkins Guide & Coaxial Position
• Non-Coaxial Position of a Small Judkins GC If a Small JL GC is Chosen, with its tip
Not Coaxial to the LM, that tip will Point Superiorly to the wall
• In that Position, Even though there is no Dampening of aortic pressure, an
Injection of Contrast Agent in young patients may not Cause Dissection, but
in Elderly Patients with Many Unsuspected Plaques, it can cause a
Small Localized Dissection

JR GC
• Relatively Little Support for Complex Anatomy, Unless Deep-Seated
• If Greater Support is Required, If the Artery is Calcified or Severely Diseased
Instrumentation of These Arteries Requires Excellent Backup Using
Shepherd’s Crook, Amplatz (AL1), or Hockey stick curves
• In this, and other Circumstances in which the GCis deep-seated, Great care must
be taken to avoid GC –Related Dissection of the Proximal Artery

JR GC. GC with Low Support

JR vs Hockey Stick

Right Amplatz GC : the Secondary Curve Rests Against the left aortic cusp
Left Amplatz GC :
AL GC is Designe with its secondary curve resting against the NC Posterior Aortic
Cusp , It is best in the case of :
1. Long LM
2. Superior Takeoff LM
AL GC Tip, is Pointing Slightly Downward, there is higher Danger of Ostial Injury
Causing Dissection
So there are Short-Tip Amplatz GC, which provide the same level of support and a
decreasing risk of coronary ostia Trauma
• Ampltaz GC Should be Avoided or Used with Great Caution in Ostial Lesions
Amplatz GC
Practical Handbook of Advanced Interventional Cardiology . Tips and Tricks . 2014

GC Selection :
Size 1 is for the Smallest Aortic Root,
Size 2 for Normal,
Size 3 for Large Roots
• If the tip does not reach the ostium and keeps lying below it, the GC is too small.
• If the tip lies above the ostium, or the loop cannot be opened, the guide is too
large
 When RCA Ostium is Very High, the Left Amplatz GC may be Used to Engage the
Right Ostium
Amplatz GC

AL GC

Amplatz GC Position
Appropriate GC Position
Tip of the Amplatz GC is inside the LM or RCA ostium, the Primary
and Secondary Curves of the GC should form a Closed loop with the
tip Coaxial to the ostial Segment.
Undesired GC Position
This is the If the guide is pulled back, its tip could dip farther into the
LM and increase the risk of LM dissection. Under fluoroscopy, while
the guide is in a relaxed mode, the is a more Open Loop with the Tip
pointing down the inferior wall of the ostial segment

Withdrawal of an Amplatz GC
• Amplatz Catheters must be Carefully Disengaged from the coronary artery.
• Simple withdrawal from the vessel in a manner similar to a Judkins catheter can
Cause the tip to advance Further into the Vessel and Cause Dissection
To Disengage the Amplatz Catheter :
• First advance the GC slightly Under fluoroscopy to Prolapse the Tip Out of the
Ostium . Rotate the GC so that its tip is moved away from the ostium Before
Pulling the GC – this is Called the “ Push-and Turn ” Maneuver

1. The First Best Technique is to Pull the balloon out while simultaneously pushing
the GC in to prolapse it out. The Procedure has to be done under fluoroscopy to
monitor the calculated movement of the GC tip
If the above maneuver fails :
2. The Second Technique can be used. The deflated balloon should be advanced
slowly to back out the guide. As the guide stops backing out, it is withdrawn slowly,
while watching the tip in order to avoid scratching the inferior aspect of the ostial
segment

• Long Secondary Curve that is Designed to Provides a Large Area of Contact
Between the GC and the aortic wall , so that the tip in the coronary artery is not
easily displaced and hence provides a Very Stable Platform
• Extra Backup Positioning
1. Advancement of the tip of the guide with a wire protruding into the AA, at the
AV sinus, below the Coronary Ostium
2. Wire is removed
3. GC is flushed
4. GC is Advanced, or withdrawn gently while Torquing a Clockwise to point it up
5. after this it can be Torqued Clockwise to move the tip Posteriorly or
Counterclockwise to move the tip Anteriorly
Extra Backup GC

• Extra back-up GCs are more Commonly used for LCA intervention.
• The Voda catheter (Boston Scientific) was the first Extra Back-up
curve catheter marketed in the early 1990s
Other extra back-up catheters include :
• EBU (Medtronic)
• XB (Cordis)
• Q-Curve (Boston Scientific)
• For normal Body habitus and Normal-sized Aortic Root, the LMCA
Can Usually be
Cannulated Using XB 3.5 or EBU 3.5
Extra Backup GC
Euro PCR Book -2014

Extra Backup GC

In general, Clockwise Rotation leads to Deep engagement of the GC
& Counterclockwise leads to “Amplatzing” ( Both for LCA and RCA )
• Both Left and Right Sinuses of Valsalva Limit free Movement of the GC shaft
When Turned Clockwise, and rotation is transmitted linearly, Leading to Deep
Insertion Into the Artery
• In Reverse, with Counterclockwise Rotation, Because there is Enough Space from
the Non-Coronary sinus , it is possible for the shaft to torque inside the
Non-Coronary sinus and obtain Support from the Contralateral Aortic wall
Deep Seating vs Rotational Amplatz Maneuver

• Enhance the Support Role of a JL GC , BY Rotational Amplatz
Maneuver
1. Gently Pushed Down while torqued Gently Clockwise so whole GC
simulates the position achieved by an Amplatz GC
2. The GC should be torqued Over the Shaft of an Device (Stent,
Balloon, IVUS, etc.).
3. The Operator should not feel any Resistance when attempting this
Maneuver
4. After the Device is Advanced and Positioned in Place, the GC is
withdrawn from the artery by Reversing the Earlier Torquing Energy
Rotational Amplatz Maneuver

5. This Technique should be Performed in a Coronary Artery Large
Enough to Accommodate the GC
6. There should be No Disease at the Ostium, or Proximal or Distal
Segment of the LM
7. It is important that the size of the Judkins GC in most of the cases
must be half a size larger than that necessary to engage the artery,
e.g. if a JL 3.5 GC is Good for is in most cases not good enough for
the Amplatz Maneuver; a JL 4.0 GC is much Better
8. However, an alternative way is to exchange the JL GC for an
Amplatz or EBU GC that can provide stronger (passive) support
Rotational Amplatz Maneuver

 In a non-coaxial situation, Backup Support will not be adequate for
Advancement of Interventional Device to cross a tight lesion
 Procedure should be Attempted Only if the Artery is Large Enough to
Accommodate the GC
 There is No Ostial or Proximal Lesion
Deep-Seating GC

Guiding Catheter Selection
1. Size of the Aortic Root and Aortic Arch Configuration
2. Coronary/Graft Anatomy ( Ostium Location and Vessel
Orientation )
3. Degree of Tortuosity and Calcification of the Coronary
Segment Proximal to the Target Area
4. Access site ( TFI vs TRI )
Euro PCR Book. 2014

GC Selection
 For average American patient, 4-cm JL GC is often adequate, via TFA
 For Asian Patients, a 3.5 cm JL GC usually Fits well via TFA
 TRI Using Usually JL/Extra Backup Right RA , take One Size Smaller
than TFA ( Based on width of Aorta )

GC Selection
 In Patients with a Very Superior Direction of LM or with a Narrow Aortic Root :
A. Smaller Size JL GC with a tip pointed more anteriorly provide a coaxial position or
B. EBU GC would help to provide Stronger backup
C. High Coronary Takeoff LM , Amplatz GC Easily cannulate the LM

GC Selection
• In Patients with Horizontal or wide Aortic Root ( Chronic AI
or Uncontrolled HTN )
A. JL GC with Long Secondary Curve (size 5 or 6) will fit the width of
the AA well
B. AL GC

JL GC Size

GC Selection

GC Selection
Judkins GC, Provide an Adequate Platform to advance the Device, As
an Ideal GC in Aorto-ostial Lesion Stenting
 The Amplatz-Type Guides are Probably Better Situated in
Ostially Stented Lesion, by Pushing the GC, its tip would lift up

GC Selection
 JL is Good In the case of Short LM or Separate Ostium :
1. Maneuver : Slightly withdraw the GC and turn Clockwise, The tip
will Point Posteriorly, Toward the LCX and Counter CW for LAD
If this Maneuver Does not Achieve Satisfactory Results
2. Change to a Larger size GC or Smaller GC
3. Use of Amplatz-Type GC ( 1.5 or 2 )

GC Selection
 As the Tip of the Judkins GC points Superiorly, better Axial Support
for LCX lesions Can be Obtained Using an Amplatz or EBU GC
 If the LM is Short and there is No Acute Angle at the Bifurcation
with the LCX,
JL GC May be the First Best Choice

GC Selection
 If the LM is Long and the Angle between the LM and LCX is Acute,
EBU GC Should be Chosen
The Rationale for this Choice is that the Tip of an EBU GC is very close
to Ostium of the LCX, so the Acuity of the LM and LCX Angle is Nullified

The RCA usually arises anterolaterally from the right coronary cusp
In the large majority of cases, its Proximal Segment has Horizontal Configuration
In most cases of RCA with Horizontal Takeoff
1. JR 4 GC can Easily Engage the ostium.
When a JR guide Fails to Cannulate the Right Ostium
2. AR GC would be the next option
3. If this fails, AL GC would be the next option
Guide for RCA Lesions

Superiorly Oriented takeoff RCA
Tip Pointing up GCs are necessary. The JR GC , which is effective in
may not provide sufficient backup
therefore the AL GC is usually selected.
Other guides with a superiorly directed tip, such as the Hockey
Stick, the LCB, IMA, or the EBU

Inferiorly Oriented Take off angle
In this Aggressive Engagement of the Tip from a Regular JR tip can cause dissection.
GC s with inferiorly directed tips, such as the ,MP, and Amplatz Guides, are more
Effective Coaxial Alignment with the Proximal Vessel Segment

• SVGs to the RCA :
1. MP Catheter if the Takeoff is Vertical
2. JR or RCB catheter if it is more Horizontal
Bypassed Grafts GC

• SVG to LCA :
1. JR
2. LIMA
3. LCB
4. AL1
Bypassed Grafts GC

• LIMA :
1. LIMA
2. LCB
Bypassed Grafts GC

Workhorse GC For TRI
1. Extra Backup Catheters ( EBU, XB, Voda, Q-Curve, Muta )
2. Modified Long-tip Catheters (Ikari, Kimmy, Power Backup,
Fajadet)
Providing Back-up Support Using the Contralateral Aortic wall Take
Consideration the Angle Between Brachiocephalic Trunk and AA
GC in TR-PCI
Euro – PCR Book 2014

• Left TRI can be Performed using standard GCs Developed for TFI
Most of the TFI Catheters can also be used for Right TRI, though the
catheter Support is Generally Less
• In TRI, the backup force of JL-3.5 is Greater than that of JL-4.0
• In addition, the Smaller-sized Radial Artery Limits Catheter Size
Available for TRI , Circumvented by Sheathless GC
GC in TR-PCI

GC in TR-PCI
SCAI Board Review 2014

GC in TR-PCI

• The Left Judkins Catheter is Suitable for Noncomplex Lesions or
LM PCI when Catheter Support is Not Critical
• IMA TRI is Usually Performed Using an IMA or JR Catheter via
Ipsilateral RA
• Cannulation of SVG or Radial graft (with Origin in the ascending
aorta) is Easier From the left RA , with standard catheters such as
JR, LCB, AL, or MP
• Their cannulation Can be Difficult from the Right RA due to the
Proximity of the Origin to the Innominate (Brachiocephalic) Artery
GC in TR-PCI

• Major Limitation of TRI is GC Size, Restricted by Radial Artery Diameter and its
Tendency to Spasm
• Constrain Options in PCI , Particularly for Complex Coronary Lesions Requiring
Adjunctive Devices and Techniques
• The main Concern is the risk of RAO, Major Predictor of RAO is a Larger Ratio of
Sheath Diameter to RA Diameter
• A Japanese study, demonstrated that the radial artery lumen is smaller than a 7
Fr sheath in 29% of men and 60% of women, and Smaller than a 6 Fr sheath in
15% of men and 28% of women.
GC in TR-PCI
CV Catheterization and Intervention 2018 Euro PCR Book. 2014

Allows TRI to be Performed with Smaller devices
1. This includes Improved Sheath (e.g., Glidesheath Slender ( Terumo Medical
Corporation ) which has an ultra-thin wall
2. Sheathless Eaucath GC ( Asahi Intec, Nagoya, Japan), Hydrophilic-Coated GC,
That does not Require an Introducer sheath
• Enhances Catheter Trackability, and Reduces the Risk of RA Spasm and Patient
Discomfort
• Long Dilator is Provided with each GC , This is Removed Once the GC tip
approaches the Coronary Ostium
Minmally Invasive TRI Approach

SHEATHLESS GUIDE CATHETERS
GC in TR-PCI

SHEATHLESS GUIDE CATHETERS
• TRI Performed Through a Sheathless GC may be Effective and Safe
in Elective PCI and in PPCI ( Large Japanese series of 478 patients
with Success Rate : 97 % )
• Studies Showed Patients Undergoing Bifurcation PCI Demonstrated
Feasibility and Safety of the Sheathless Catheter, with No
Crossover to the FA and no Major Complications
GC in TR-PCI

• It is Generally advisable to start before Intervention with Aortography in LAO
and RAO Projections to obtain a Clear view of Ostial Positioning, which saves
Time and Decreases risks of Unnecessary maneuvering for Cannulation
Guides for Anomalous Coronary Arteries Arising from the Left Sinus
When the RCA arises from the left cusp, usually it is anterior and cephalad to the LM
1. JL GC with the Secondary Curve One Size Larger
2. AL 2,3 ( 12.5 % )
3. EBU GC ( 37.5 % )
4. MP 1,2 ( 50 % )
GUIDES FOR CORONARY ANOMALIES

GC for Anomalous Coronary Arteries Arising from the RCC
Most Common Type : LCX from RCC
GCs :
1. AL
2. AR
3. MP

Guides of the Ectopic RCA
Step 1 : After failing to Selectively image the RCA with
perform a Right sinus injection at the LAO 30–40° This to
delineate takeoff and orientation of these RCAs
Step 2 : Use an AL-0.75 to -1.0 ( Depending on the Size of
the Aorta), and in the RAO 30–40° projection, with the
Catheter pointing Anteriorly and Slightly Caudal, attempt to
image the RCA originating from the anterior third of the
right coronary sinus (also known as an “Anteriorly
Displaced RCA”)

Guides of the Ectopic RCA
Step 3 : Using the Same AL-1 in the AP view, locate the LM.
Turn the catheter counterclockwise in order to twist the tip
anteriorlyand then push forward to advance the tip
higher.The ostium ofthe RCA is suspected to be Anterior and
Cephalad to the LM
Step 4 : If the RCA cannot be seen, Repeat the Injection
above the Left coronary ostium to image the Ectopic RCA
with a Higher Left Sinus Takeoff

Guide support can significantly facilitate every PCI step, including
wiring and balloon or stent delivery, and can be accomplished by :
(1) Large-Diameter (7 or 8 Fr) GC
(2) More Supportive Shapes ( Such as Amplatz or EBU )
(3) Coaxial Alignment of the GC with the Coronary Ostium
(4) Deep GC Intubation
Deep GC Intubation Carries the Risk of :
A. Pressure Dampening, Compromising Blood Flow and Leading to
Ischemia
B. Coronary Dissections
Guide Support

BEST Technique in Strengthening GC

• Second Angioplasty Wire Can be advanced Parallel to the
first one
• It Straightens the Tortuous Vessel and Provides Better
Support for Device Tracking
• If one Extra wire Does not help maybe Two or Three
Buddy wires may help to Advance any Devices
Stabilizing GC with the “Buddy” wire Technique

• When working with an Unstable GC , Second Small
Balloon ( 1.5– 2.5 mm Diameter) can be inserted in a
Small Proximal Branch or Distal Vessel and Inflated at
2–5 atm in order to Anchor the GC without letting the
GC Back out
Anchor Balloon Technique

For Proximal Placement, the wire is advanced into
• Another Vessel (e.g., LCX for LAD lesion)
• Side Branch
A. Conus Branch for Mid RCA lesion
B. Diagonal Branch for Distal LAD lesion
C. OM Branch for Distal LCX lesion
Anchor Wire Technique

• Therefore, GCs with Relatively Simple Curves
(Amplatz, MP, EBU) are Probably Safer and Better suited
for this Technique
• Disengaging the GC from the Coronary Ostium should be
Performed only after the Sheath is Retrieved away from
it, Probably to the Descending Aorta, with the GC Fixed
in Place
• ( Larger Fr size will Give more Support ) and the Height
of the Patient Taller Patients will Require Longer Sheaths
Stabilizing GC with Long Sheath

When a Lesion Could not be Crossed by a Balloon or Stent
in the Regular 6-Fr system, the Five-in-Six System could be
tried (“Mother in Child”)
Strengthening the GC with Another GC or Catheter

GuideLiner – Vascular Solutions Product
• This allows advancement of a Device through a Tortuous,
Angulated, or Calcified Proximal Segment without
Getting Exposed to Friction from the Vessel Wall
• is Contraindicated in Vessels that are <2.5 mm
• Avoiding Stents >4 mm diameter

Guidion – IMDS Product

• De Man et al GuideLiner Catheter Extension in
65 Consecutive Patients with Predominantly Complex
and Distal Lesions with a Success rate of 93% and
without any major complications
• Series of 28 Cases of GuideLiner-facilitated PCI to CTO
Lesions Resulted in a Successful Delivery of
Microcatheter or Small Balloon Across the Culprit Lesion
in 86% cases
• Another Series of 83 patients Stated a Procedural Success
Rate of 73% without major Complication
GC Extension Studeis

• Despite Very Deep Intubation and Aggressive
Intervention Techniques, No Cases of Vessel Dissection,
Perforation, or Distal Embolization have been reported in
the literature
• In summary, GC Extension systems may Safely Provide
Greater backup resistive force and Improved alignment
for Stent Delivery in Unfavorably Tortuous Coronary
Arteries and Complex, Heavily Calcified and often Distally
Located lesions, which otherwise may have been
Considered Unsuitable for PCI
GC Extension Studeis

Changing a GC with wire Across Lesion

1. First withdraw the GC a Few Centimeters without Losing Position of the wire
2. When the Proximal End of the GC meets the Proximal End of the wire, attach
a Syringe full of fluid into the GC . Under fluoroscopy, withdraw the GC while
keeping the wire Immobile by continuing to inject fluid into the GC from the
Syringe. By this, the GC is Removed Slowly
3. Once the GC is out of the Sheath, New GC is inserted over the two wires :
The angioplasty wire across the lesion and 0.035-inch wire
Exchange of a GC without Removing the wire

4. When the GC is at the ascending aorta level the 0.035-inch wire is removed
5. A Balloon catheter with very small size (1.25 × 10 mm or 1.5 × 10 mm) is
inserted as far as possible to provide a Good rail for GC insertion
6. Once the balloon catheter is at the ostium of the coronary artery, the new GC
is then advanced over the Shaft of the Balloon Catheter, which Can Provide
Better Rail for the GC than the wire alone would
Exchange of a GC without Removing the wire

Evolution in
Guiding Catheter
Design

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