Guide catheters are essential tools for Pecutaneous Coronary Intervention • Understanding construction, design & performance characteristics facilitate their appropriate selection • Selection of Guide catheters seems elementary but makes the difference between a successful and failed PCI procedure

1. Satyam J Shukla
Diagnostic & Guiding Catheter
used in PTCA

2. Components of Percutaneous coronary intervention equipment.

4. Diagnostic Catheter Guide Catheter
Thicker shaft Thinner shaft
Internal Dm Small Internal Dm Larger
Tapering Tip Non Tapering Tip
Less Reinforced More Reinforced
Difference between Diagnostic & Guide Catheter

5. Diagnostic catheters
Judkins L
• Left
radial JL 3.5 Femoral JL4

6. Judkins R – JR4 For Radial and Femoral
Radial & Femoral – RCA- JR4

7. Multipurpose Radial - Tiger

8. Shapes used for coronary grafts

9. Diagnostic catheter shapes
•Femoral –Judkins - JL4, JR4
– large JL5
– Small JL3.5
– Other - Williams, AL1
•Radial
–Judkins - JL3.5, JR4 - Tiger
Summary

10. The Guiding Catheter
A special large-lumen catheter (5–8F) is used to deliver the
coronary balloon catheter and other interventional devices
to the target lesion.

11. •Support for device advancement
•Path for device and wire transport
• Vehicle for contrast injection
• Measurement of Pressure
Functions of a Guide Catheter

12. Parts of a Guiding Catheter
Usual Length is 100 cm
Tertiary curve is available in some Catheters

13. Guiding catheters are made up of three layers
Inner polytetrafluoroethylene layer that is slippery,
A middle stainless steel braided layer.
Outer soft nylon elastomer jacket
Cross section of catheter

14. Guide Selection
The guide catheter is usually firmly supported against the aortic
wall opposite to the coronary sinus from which the artery arises.
Selection is dependent on
•Side holes
•French sizes[Fr]
•Length
•Type of curve
 Anatomy based
Size of the aortic root
Ostial origin and takeoff
•Support
Active Support
Passive Support
• Anomalous origin

15. Side Holes
Side holes prevent ventricularization or dampening caused by engagement
of guide significant ostial lesions, misalignment of guides, during coronary
spasm, or when a large Fr guide is used for engagement of a smaller coronary
artery
Advantages Disadvantages
Maintains
coronary
artery
perfusion
False sense of security as it monitors
aortic not coronary
pressure
Suboptimal opacification
Increase in contrast volume
TERUMO-Climber TM

16. French Sizes
Ideally use the smallest diameter catheter feasible to minimize the risk of arterial
damage.
Larger French catheters have the advantage of improved opacifi cation, better guide
support and allow for pressure.
•Usually 6 Fr guides will suffice for most interventions.
•7 Fr: Two-stent strategy for bifurcation lesions and rotational atherectomy burr of 2
mm.
Guide Length
•Regular 110 cm guides will suffi ce for most coronary interventions.
•Long saphenous vein graft (SVG) or internal mammary artery (IMA) grafts
interventions may require the use of short 80 or 90 cm guides

17. Up to 250+ shapes available

18. Aortic width

19. Curve length = distance between P
(primary curve) & S (secondary curve)
•Aortic diameter determines the curve length
Aortic width

20. GUIDE CATHETERS FOR TRANSFEMORAL INTERVENTION
Most common catheters
– Judkins
– Amplatz
– Extra Backup support
EBU (Medtronic)
XB (Cordis)
Voda, Qcurve (Boston)
• Catheters with niche use
– Multipurpose – RCA graft, High LM takeoff
– IMA cath –
LIMA, Superior takeoff RCA or RCA graft
– LCB, RCB cath – SVG

21. JL – primary (35°) Secondary(180°) and tertiary
(35°)curve fitting aortic root anatomy engages
LMCAostium without muchmanipulation
JR – requires clockwiserotation to engage RCA
Judkins

22. Judkins

23. The Amplatz Guide
•Secondary curve rest against the noncoronary
posterior aortic cusp
•Offers firm platform for advancement of device
• Best in the case of a short LM, with downgoing
left circumflex artery (LCX)
•Tip points slightly downward -higher danger of
ostial injury causing dissection

24. The Amplatz Guide
• Selection of the proper size for an Amplatz guide is essential
– Size 1 is for the smallest aortic root
– size 2 for normal
– size 3 for large roots
• Attempts to force engagement of a
preformed Amplatz guide that does not
conform to a particular aortic root
increase risk of complication
• If tip does not reach the ostium and keep
lying below it - guide is too small
• If tip lies above the ostium - guide is too
large
• When RCA ostium is very high - left
Amplatz guide may be used to engage
the right ostium

25. Long tip catheters (Extra Support)
• Voda, XB, EBU
• Advantages
– coaxial intubation
– better support & stability due to large area of contact between
catheter & contralateral aortic wall
– precise control and manipulation
– lack of bends
– improve advancement of devices,decrease the loss of supportive
forces
–Safety

26. Extra-Back-Up Guide
• Long tip forms a fairly straight line
with the LM axis or the proximal
ostial RCA
• Long secondary curve - abut the
opposite aortic wall
• So tip in the coronary artery is not
easily displaced
•Provide a very Stable platform

27. Multipurpose Guide
• Straight with a single minor bend at the tip
• For RCA bypass graft or a high left main (LM) takeoff

28. Other catheters
3 DRC –
Three dimensional right curve - for tortuous, bent anatomy and
posterior or superior take off of RCA
• Arani
• Double angle 90° curve sits on ascending aorta in S
configuration and is therefore useful for RCA with horizontal take-
off & shepherd crook RCA
•Primary and secondary curve provides two contact points on the
opposite side of aorta thus providing tremendous back-up

29. • El Gamal (EGB) - pre-shaped catheter with improved distal end-portion for accessing
bypass grafts and more precise access of RCA
• LCB - for left coronary venous bypass grafts. Its tip has 90 º bend with 70º secondary
bend.
• RCB - for right coronary venous bypass grafts, its tip and secondary bends
approximate 120º - like a JR catheter with ashallower tip bend
Other catheters

30. Aortic root
•Normal JL4
•Dilated JL ≥ 5, AL ≥ 2, VL ≥ 4, , XB ≥ 4, EBU ≥ 4
•Narrow JL3.5, VL3.5, XB3.0, EBU3.5
• Orientation
•Normal, Anterior JL, AL, VL, XB, EBU
•Posterior AL, VL, XB, EBU
•Superior JL, VL, XB, EBU
Guiding Catheter Selection - LCA

31. Aortic root
•Normal JR4, AL1, AR1
•Dilated JR ≥ 5, AL ≥ 2, AR ≥ 2
•Narrow JR 3, AL ≤ 0.75
Orientation*
•Normal JR, AL, AR
•Anterior, Superior AL, HS, MP
•Inferior MP, AR, JR
•Shepherd Crook AL, VR, VRSC, ELG, HS, IMA, Champ
•Horizontal JR, HS, AR, VR
Guiding Catheter Selection - RCA

32. Guiding Catheter Selection - SVG
• RCA graft usual location : Primary – MP
Alternate – JR, AL, RCB, HS, EGB
• RCA graft anterior location : Primary – AL
Alternate – JR, MP, HS
• LCA graft : Primary – JR, HS
Alternate : AL, LCB, MP, EGB (El Gamal)
• LCA graft ant location : Primary – AL, HS
Alternate : JR, LCB,

33. GUIDE CATHETERS FOR TRANSRADIAL INTERVENTION

34. Choice of Catheters for TR-PCI
• Left coronary artery: down size JL by 0.5
– Judkins left, Amplatz left, Multipurpose, EBU
– Ikari left, El Gamal
• Right coronary artery
– Judkins right, Amplatz right, Amplatz left,
Multipurpose, EBU-R
– Ikari right, El Gamal
• Single catheter strategy
– Ikari left, Kimny, Barbeau, Fadajet

35. Guide catheter choices

36. Guide selection: L system guides

37. Guide catheter choices: EBU

38. Universal guide catheters
Radial Brachial (RB) -Cordis

39. Terumo Ikari guide catheters

40. Guidewires used in the PCI

41. Guidewires:
•Guidewires (solid wires navigated within the vascular system / extra‐ vascular tract)
act as a lead point for catheters, allowing operators to traverse along a given vessel / track.
•General Types of Guidewires:
•Starting guidewires ‐ used for catheter introduction and some procedures.
•Selective guidewires ‐ used to cannulate side branches or cross critical lesions.
•Exchange guidewires ‐ are stiffer and used to secure position as devices are passed over the
wire.

42. Length
•Must be long enough to cover the distance both inside and outside the patient.
•Must also account for access well beyond the lesion, so that access across the
lesion will not be lost intraoperatively.
•Usually varies from 145 to 300 cm.
Diameter
•Vascular catheters are designed with a guidewire port of specific diameter.
•Most procedures are performed with O35 guidewires (0.035 in.).
•Small‐vessel angiography requires 0.018–0.014 in. guidewires.

43. Purpose of the Guide wire
• To access the lesion
• To cross the lesion atraumatically
• To reach far end of the vessel
• To rail the devices into coronaries
• To provide support for interventional devices

44. Components of Coronary Guide wire
Core
Tip
Cover
Core Material
• Stainless steel (SS): Strengths : provide optimal
support, transmission of force, torque
characteristics, But susceptible to kinking
•Nitinol :More Flexible & kink resistance But less
torqueability than SS.
Core Diameter
Larger the Diameter Better the support & torqueability.
Core Taper
Continous or segmental
Shorter tapers enhance the push force & pushability ,
while longer tapers enhance the flexibility
Coronary
Guide wire

45. Components of Coronary Guide wire
Core
Tip
Cover
The tip refers to the distal end of the guidewire.
There are two types of tips.
covered with coils (spring-tip guidewires)
 polymer (polymer-tip guidewires)
2 type Of Design
Core to TIP Design- one-piece core where the core
extends all the way to the tip with a variable taper
Two-piece or shaping ribbon The core stops just
before the distal tip. A shaping ribbon (a small piece of
metal) bridges the gap between the end of the core and
the distal tip
(these wires have less reliable torque control)
and a higher likelihood to prolapse.
Coronary
Guide wire

46. Components of Coronary Guide wire
Core
Tip
Cover
To maintain the overall diameter of 0.014 in., all
guidewires have a specifi c surface coating:
Hyderophobic
Hydrophobic coatings are silicone based coatings which
repel water and are applied on the working length of the
wire, with the exception of the distal tip
Advantages
More controllable (and therefore less likely to dissect) •
Provide better tactile feel
Challenges
• Poor trackability
• Wire tip becomes stiffer, torque response increases,
but less tip resistance is transmitted to the operator,
making it easier to enter a false channel.
Coronary
Guide wire

47. Components of Coronary Guide wire
Core
Tip
Cover
Hydrophilic Coating
Applied over the entire working length of wire including
tip coils
• Attracts water - needs lubrication
• Thin, non slippery, solid when dry→ becomes a gel
when wet
– ↓friction
– ↑trackability
– ↓Thrombogenic
– ↓tactile feel
– ↑risk of perforation
Useful in negotiating tortuous lesions and in “finding
microchannels” in total occlusionschannel.
Coronary
Guide wire

49. The Amplatz super-stiff and ultra-stiff guide wires (Cook
Medical, Bloomington, Indian are the mainstay for almost
every case in stabilizing balloons across high-flow lesions
and during stent implantation or valvuloplasty
Different type of Guidewire & Their Uses
(0.025 to 0.038 inch)
coronary wires are important to have on hand to engage
coronary fistulas and small tortuous arterovenous
malformations.
(0.014 inch)
The Meier Backup wire (Boston Scientific) and Lunderquist
extra stiff wire (Cook Medical) have been invaluable for transcatheter
pulmonary and aortic valve implantation when tortuosity
and calcification is a problem.

50. Guidewire Depend upon the Shapes of the Distal end
Wires with various sized curves. The distal 1- to 20-cm end of a wire is often
distinct in design and maneuverability from its remaining length; this end often
determines a wire’s utility.

51. Shaping of the Guide wire

52. Selection of Guidewires
The selection of a guidewire should be primarily determined by
• Vessel morphology
•Lesion morphology
•Device properties.

53. Guidewires for Standard Lesion Morphology
A standard lesion is defi ned by the absence of complex
characteristics A “workhorse or frontline” wire is most suitable for
standard lesions. The workhorse wire, which accounts for about 70
% of all coronary wires used, is a fl oppy wire with atraumatic tip
which provides low to moderate support.
Guidewires for Chronic Total Occlusions
For the more complex lesions, particularly chronic total occlusions
(CTO), a stiffer wire with increasing support may be required.

54. Selection of Guide wires