This document provides a brief history and overview of common devices and procedures used in interventional cardiology. It discusses the development of cardiac catheterization from early experiments in animals in the 18th century to modern percutaneous techniques. Key events included the first human cardiac catheterization in 1929 and the first percutaneous coronary angioplasty in 1977. The document then describes techniques for vascular access, coronary cannulation, and performing coronary angiography and angioplasty procedures via the femoral or radial arteries.

1. Common Devices and procedures in
Interventional/Invasive Cardiology
By: Seifu Bacha; MD, Internist & Cardiologist
SPHMMC Cardiology Division
November 2023

2. Outline
• Brief History of invasive cardiology
• Vascular access techniques
• Guide catheters and Guide wires
• Balloon catheters and Stents
• Common Invasive Cardiac procedures

3. History of cardiac catheterization
Some of the investigators include
• Rev. Stephan Hales in 1711
• used brass road in femoral A measured BP of a horse
• Claude Bernard in 1844
• Catheterized horse ventricles retrogradely;
• Coined the term “cardiac catheterization”

4. History of cardiac catheterization
• Chaveau and Marey in 1861
• published measurement of intracardiac pressure;
• apical beat and LV systole; aortic and LV simultaneous pressure
• Andre Cournand and Dickinson Richards at Columbia
University
• Hemodynamic exploration and intracardiac pressure measurement in
normal subjects and congenital heart disease

5. HIMSELF
Werner Forssmann
First cardiac catheterization of a living person
In 1929

6. History of cardiac catheterization
• Retrograde left heart catheterization
• first reported by Zimmerman and Limon-Lason in 1950
• The percutaneous (rather than cut-down) technique
• developed by Seldinger (radiologist) in 1953

7. History of cardiac catheterization
• Selective coronary arteriography
• 1st accidentally by Mason Sones (pediatric cardiologist) in
1959
• 1967- Melvin Judkins- specially shaped catheters to perform
selective angiography
• Modified CAG for Percutaneous approach
• in 1959 and 1967, By Ricketts, Abrams and Judkins
• Swan and Ganz
• In 1970
• Developed a flow guided balloon tipped catheter

8. Revascularization–Restoration of Blood Flow
• 1964 –First concept of percutaneous revascularization
(Charles Dotter and Judkins)
(used spring-coil guide wire with large rigid dilator)
• 1974 -Percutaneous transluminal peripheral
angioplasty
Andreas Gruentzig- series of experiments in animals,
cadavers)
• 1977 -Percutaneous transluminal coronary angioplasty
(Andreas Gruentzig) On a conscious human

9. The patient, 38-year-old Adolph Bachman, underwent successful angioplasty to a proximal left
coronary artery lesion in Sep.16, 1977

10. Revascularization–Restoration of Blood Flow
Intracoronary stents
• Successfully deployed 1st in 1986
• Lowered restenosis rates from 30–50% to 15–30% ,
• By markedly reducing
• elastic recoil and
• negative remodeling

11. Approach for cardiac catheterization
• In early years , coronary angiography was used to be
performed using the brachial artery cutdown approach;
• Further advancement led to percutaneous approach from
the femoral, brachial, or radial artery, and brachial cutdown
is rarely performed now a days .

12. Preparations and premedication
• NPO after midnight except for medication
• Shave inguinal area
• Light shower
• Consent
• Conscious Sedation
• Midazolam 0.5mg IV PRN
• Fentanyl 25-50mg IV

13. Vascular Access
• Approach= Percutaneous
• Venous catheterization performed via
• The femoral,
• Internal jugular,
• Axillary,
• Subclavian , or
• Median antecubital vein;
• Arterial catheterization can be performed via
• The femoral,
• Brachial,
• Radial arteries,
• Lumbar aorta.

14. Percutaneous Femoral Artery CAG Technique
• CFA is the standard access for many years ,

15. Percutaneous Femoral Artery CAG Technique
• Patient preparation for femoral A/V catheterization
• Localize pulsation FA/ Shave 10cm diameter/
• Prepare both groins
• Clean puncture area with chlorhexidine-alcohol based antiseptic
• Drape from clavicles to below the feet leaving groin exposed
• Conscious sedation
• Locate femoral pulsation
• Local Anesthetics 10-20 ml 1% or 2% Lidocaine/ Xylocaine

16. Percutaneous Femoral Artery CAG Technique
• Locate Inguinal ligament
• And then femoral artery
• 1-2 cm below inguinal ligament
• Don’t use skin crease
• Aim for mid common femoral
artery
facilitates vessel entry &
effective compression;

17. Percutaneous Femoral Artery CAG Technique
• Fluoroscopy
• AP view
• Localize Ibfh (inferior border of femoral
head) by forceps
• Or intra-procedure ultrasound
• FA: Pulsating, circular, non-compressible

18. Materials for puncture
• 18-gauge single-wall puncture
needle
• 18-21 gauge thin-walled
Seldinger needle with
Obturator;
• Micropuncture® Introducer Set
:
• 21 gauge needle ,
• 5F introducer and dilator and
• 0 .018-inch nitinol wire

19. • A sheath and dilator equipped with a back-bleed valve
and side-arm connector with 0 .018-0.038-inch J
guide wire;
• The sheath size should be at least equal to the
catheter size used;

20. Technique
• “Bounce" technique
• Puncture needle proximity to the artery can be confirmed based on
transmitted arterial pulsation;
• North to south movt. needle…top of artery
• Side to side movt…when needle is lateral to artery
• Puncture technique
• Seldinger
• Modified Seldinger/ Anterior wall

21. Seldinger Technique

22. Modified Seldinger Technique

23. Percutaneous Femoral Artery CAG Technique
• Never use force when advancing is difficult;
• Fluoroscopy ….may show tip in branch…slightly withdraw and
reorient;
• Tip of needle may be back wall…depress the unit
• Control proximal end of the guide-wire and that it is held in a
fixed position as the sheath and dilator are introduced;
• Sheath and dilator are rotated as a unit to ease insertion;

24. Percutaneous Femoral Artery CAG Technique
Inappropriate localization
• Above the ligament/ high puncture
• makes catheter advancement difficult;
• predisposes to inadequate compression;
• Hematoma formation, and/or
• retroperitoneal bleeding;
• Low puncture
• fail to enter the arterial lumen;
• false aneurysm formation or
• thrombotic occlusion
• A-V fistula formation

25. Percutaneous Femoral Artery CAG Technique
• The selected catheter is inserted into the femoral sheath
and advanced around the arch and into the ascending aorta
before the guidewire is removed;
• After removal of the guidewire, the catheter is attached to
a specially designed manifold system that permits the
maintenance of a closed system;

26. Percutaneous Femoral Artery CAG Technique
• Catheter is immediately double-flushed-----blood is withdrawn
and discarded, after which heparinized saline flush is injected
through the catheter lumen;
• Difficulty in blood withdrawal suggests apposition of the
catheter tip to the aortic wall…corrected by slight withdrawal
or rotation of the catheter until free blood aspiration is
possible.
• If not….remove catheter and flush it in towel to see any
thrombus collected in the catheter;

27. Percutaneous Femoral Artery CAG Technique
• The lumen of the introducing sheath should also be flushed
immediately before and after each catheter insertion and
every 5 minutes thereafter;
• Alternatively, the side arm of the sheath may be connected
to a 30 ml/hour continuous flow regulator.

28. Percutaneous Femoral Artery CAG Technique
• Always start by “Zeroing” the pressure to Atmospheric
pressure
• Once the catheter has been flushed with saline solution, tip
pressure should be displayed on the physiologic monitor at all
times (except during actual contrast injections);
• Recording this baseline pressure before contrast
administration serves as an important baseline reference
point;

29. • Any subsequent alteration in that waveform during coronary
angiography may signify
? Damping
• A fall in overall catheter tip pressure (because of an ostial coronary stenosis or
an unfavorable catheter position within the coronary artery)
? Ventricularization
• Diastolic pressure drops while systolic remains high

30. Cannulation of the Left Coronary Ostium
• Once the above measures are completed and all is in order,
the coronary angiographic catheter is advanced into the
aortic root in preparation for selective engagement of the
desired coronary ostium;
• Engagement of the left coronary ostium is usually quite easy
with the Judkins technique;
"the catheters know where to go if not thwarted by the operator"

31. Judkins technique for catheterization
• JL4; LAO projection

32. Cannulation of right coronary Ostium
• Requires slightly more catheter
manipulation;
• JR4 is brought around the aortic
arch with the tip facing inward
until it comes to lie against right
side of the aortic root with its
tip aimed toward the left
coronary ostium;

33. Cannulation of the Right Coronary
Ostium
• In LAO projection, carefully rotates
the catheter clockwise by nearly 180°
to engage the right coronary artery;
• The tip of the right Judkins catheter
tends to drop more deeply into the
aortic root when the catheter is
rotated;
(as tertiary arm aligns with roof
aortic arch);

34. Percutaneous Radial Artery Technique
• Increased patient safety from
• virtual elimination of access site bleeding and vascular
complications
• associated with early sheath removal,
• improved patient comfort,
• faster recovery

35. Percutaneous Radial Artery Technique
• Reasons for not adopting TRA
• Higher access failure rate
• increased radiation exposure
• incompatibility of sheaths larger than 6F
• propensity for vasospasm,
• thrombotic radial artery occlusion,
• dissections
• compartment syndrome,
• limited catheter stability,
• poor coronary engagement

36. Percutaneous Radial Artery Technique
• Average diameter of radial artery (RA)
• 2.8 mm in females and 3.1 mm in males (compatible with 6F sheaths);
• Advantages of TRA over femoral access
• ease of compression and hemostasis;
• vast collateralization of the radial artery;
• no risk of neurologic sequelae (cff Ulnar)
• Ulnar artery
• deep lying, mobile, adjacent to the ulnar nerve NOT IDEAL for
first-line vascular access

37. Percutaneous Radial Artery Technique
• Positioning
• left or the right radial artery
• Comfortable position to patient and operator
• If RIGHT
• Abduct right arm by 30 degree
• Wrist hyperextended
• Rolled towel/ dedicated splint
• Fingers taped to the arm board
• Oximeter

38. Percutaneous Radial Artery Technique
Radial Puncture
• Access techniques
• single-wall versus double-wall or back-wall technique
• kits include
• a micropuncture needle or a 20 gauge angiocath needle
• a short 0.018-0.021 inch wire,
• arterial sheath with/ without hydrophilic coating
• less spasm and patient discomfort
• 5F-6F
• shorter ( 10 to 13 cm) or longer (23 cm) length
• Adequate Sedation

39. Anterior-wall technique
• Step 1: LA
• Approximately 2 cm proximal to the radial styloid process,
• not at the wrist;
• anesthetized with
• 2-3 cc of 1% lidocaine with a small (3cc) syringe 25 gauge needle;

40. Anterior-wall technique
• Step 2: arterial puncture in front wall technique
• a short 2.5 cm, stainless steel, 21 G needle/ micro
puncture catheter needle
front wall technique

41. Anterior-wall technique
• Step 3: Access techniques-front wall technique
• Needle advanced into radial artery
• Blood return indicates intraluminal needle position
• The blood return is rarely pulsatile or brisk.

42. Anterior-wall technique
• Step 4: guide wire
• A 0.018in short guidewire advanced through the needle into the
proximal radial artery,
• The needle is exchanged with sheath

43. Dual-wall or back-wall technique,
Step 2: puncture
• A micropuncture catheter
• fine metal needle and
• 22G Teflon catheter (allow passage of a 0.018-0.021 inch
guidewire);
• Advanced through the front wall Into the lumen of the artery
• until blood is noticed in the hub and then
• intentionally pushed through the back wall of the Artery

44. Dual-wall or back-wall technique,
Step 3
• Once the tip of microcatheter and needle are through
the back wall of the radial artery, the needle is
removed and the microcatheter left in place across the
radial artery

45. Dual-wall or back-wall technique,
Step 4
• the small Teflon microcatheter is slowly
withdrawn until the appearance of brisk
pulsatile flow that confirms the distal tip is in
lumen

46. Dual-wall or back-wall technique,
Step 5
• A short 0.018 inch wire advanced through the micro
catheter;

47. Dual-wall or back-wall technique,
Step 6
• A hydrophilic-coated sheath advanced over wire

48. Percutaneous Radial Artery Technique
Step 7 (After Radial artery is accessed by either
technique)
• Once sheath is in place,
• spasmolytic cocktail through the sidearm to prevent
radial artery spasm
• 5000 U UFH given as a bolus, or 50 units/kg,
• Preferably IV
• To prevent post-procedural radial artery occlusion;

50. Pros and cons of the radial and femoral artery approach

51. Vascular Catheters
• Selection of catheter is an elementary decision, however, it
can be the difference between success and failure
• Diagnostic catheters (for diagnostic purposes) and
• Guiding catheters (for intervention)
➢come in multiple preformed shapes and sizes

52. Guide catheters
• Constructed from polyethylene or polyurethane;
(resist softening in the body);
• Distal wire mesh that allows torque creation site
• Have a stiffer shaft, larger internal diameter,
• Has a soft distal tip to minimize the risk of arterial dissection;
• MOST procedure are performed through a 6 F guide (5-8 F)
catheters;
• As a rule, the outer diameter (OD) of the guiding catheter is
the same dimension as the inner diameter (ID) of the sheath;

53. Basic Functions of a Guiding Catheter
• Provide a supportive conduit for advancement
of guidewires and devices
• Serve as a vehicle for contrast injection
• Measurement of blood pressure

54. Important Characteristics of a Guiding Catheter
• Atraumatic tip
• Proper preformed shape ( co-axial with vessel)
• Torque control
• Kink resistance
• Radiopacity

55. Guide catheters
• Measured in French (Fr), referring to the outer diameter
(Note: refers to inner diameter for sheaths)
• 1Fr= 3mm [Eg- 6Fr catheter has an outer diameter of
2mm(6 divided by 3)
• Length usually 100cm
• Choice of size of the curve depends on the aortic root
diameter- usually ranges from 3.5 to 5.0cm)
• Left/Right indicates the side of the coronary artery
• Eg: 6Fr JL4.0 indicates a Judkin’s Left catheter with
outer diameter of 6Fr and curve length of 4.0cm

62. Judkins Catheters:
• The Judkins left coronary catheter (JL):
• length of the segment between the primary and secondary
curve is what determines the size of the catheter
• length and size of the aorta…guide size selection
• JL4 catheter is optimum
• The Judkins Right coronary catheter (JR)
• sized by the secondary curve
• has a sharp primary curve and
• shallow secondary curve

63. Judkins Catheters:

64. Amplatz catheter:
• A half circle with the distal tip
extending perpendicular to the curve
• Catheter size…. diameter of the
half circle
Amplatz left catheter

65. Amplatz catheter:

68. Tiger and Jacky radial catheters
• most commonly used radial catheters;
• designed to cannulate both the left and right coronary arteries

69. Guidewires
• Used as support/guide for advancement of sheath or a
catheter (sheath wire, angiography guide wire)or
• For interventions (Eg-coronary wire) to open an occluded
vessel or cross a narrowed vessel over which a dilation
balloon and stent can be advanced
• Coronary wires are usually 0.014inch in thickness but have
different coatings, strengths at tip
• Light support (Floppy)
• Intermediate support
• Strong support

70. Basic Coronary Guide Wire Characteristics
Adequate
Rail Support
Atraumatic
Tip
Smooth
Coating
Steerable
“Deliverable”

71. Guidewire Construction
Central Core
Stainless steel Durasteel™
nitinol/Elastinite®
Tip :
Polymer sleeve
or
Coil-Spring Tip
Platinum
Tungsten
Stainless Steel
Lubricious
Coating
Silicone
PTFE
Hydrophilic
3 basic components

74. Core Diameter
Diameter affects flexibility, support and torque
Smaller Diameter = More Flexibility
Larger Diameter = More Support & Torque

75. 75
Core Taper
Longer taper- superb wire tracking, less prolapse
Shorter taper- longer segments of consistent support, more prolapse

76. 76
Core Taper
• Abrupt or short tapers produce a core which provides
greater segment length of support but also greater
tendency to prolapse
Prolapse

77. 77
Core Taper
• Broad, gradual or long tapers produce a core which
offers greater tracking and wire which prolapses less
Successful
Tracking

78. 78
Core Material
• Stainless steel
– Original core material technology
– Good support, push force and torque
– Less flexible than newer core materials

79. Core Material
• Nitinol/Elastinite®
– Super-elastic alloy designed for kink resistance
– Excellent flexibility and steering
– Durable nature may facilitate treatment of
multiple lesions and/or tortuous vessels
– No memory

80. Work-Horse Guide Wire Characteristics
• Intermediate Core Diameter
• Gentle Core Taper
• Resilient Core with good torque control
• Soft Tip
• Coils or Covers
• Smooth Coating

81. Change Coronary Guide Wire Characteristics
Adequate
Rail Support
Atraumatic
Spring Tip
Smooth
Coating
Steerable
“Deliverable”
Stiff
Tip
Dissections &
Perforations
Increased
Rail Support
Straightening
Artifacts
Hydrophilic
Coating
Perforation

82. Balloon Catheters (Balloons)
• Used for dilation of a narrowed vessel
• Both for coronary and peripheral arteries
• Over the wire vs Monorail/rapid exchange (widely used)
• Different types, mainly 3
• Differ on the distribution and amount of pressure applied on
the diseased and surrounding normal vessel when inflated

83. Balloon Catheters (Balloons)
• Complaint = made of polyurethane or silicone. Inflated by
volume instead of pressure from 100-800%- rarely used
• Semicomplaint = mid pressure balloons- more compliance and
more flexibility than NC
• Non Complaint (NC)= high pressure balloons- made of
polyster or nylon. Used when balloon needs to expand to a
specific diameter and exert high pressure

84. Balloon Catheters (Balloons)
• Size variable from small to large
• Labelled with the format of “X” mm by “Y” mm where the
first number (X) refers to the diameter when inflated and
the second (Y) the length of the balloon
• Eg; “3.5 * 12mm NC” labelled balloon implies- a non complaint
balloon of diameter 3.5mm and length 12mm (1.2cm)
• Inflated using an inflator deflator device with a pressure
gauge indicating the amount of pressure applied (in unit of
atmosphere)

85. Balloon Catheters (Balloons)
• The balloon pack is labelled with the amount of pressure
required to achieve a given diameter
• Nominal Pressure (NP)- the pressure at which the balloon
reaches its labeled diameter
• Rated Burst Pressure (RBP)- pressure at which 99.9%of
balloons can survive

88. Stents
• A very thin but strong wire mesh tubes wrapped around a
balloon and placed at the site of the dilated lesion after
which the balloon is inflated and deflated leaving the stent in
place
• Prevents recoil and re stenosis of the artery
• Nomenclature of size (diameter and length), delivery
mechanism similar to balloons

89. Stents
• Gradually evolved since first discovery to this date
• Mainly two types
• BMS (bare metal stent)- used in the past with a relatively
higher rate of restenosis
• DES (drug eluting stent)- coated with different types of
drugs which are released gradually and prevent inflammation,
hence reduces risk of restenosis better than BMS

93. Common Invasive Procedures
• Less commonly used, not widely available, expensive, high
complication rates
❖When non invasive tests are inconclusive or not available or
intervention is planned at same time
• May include:
oLeft Heart catheterization
oRight Heart catheterization
oElectrophysiological studies
o

94. Left Heart Catheterization
• Coronary Angiography
• LV angiogram
• Measurement of gradients, valve regurgitation
quantifications-less commonly used after advent of modern
echo machines

95. Right Heart catheterization
• Monitoring of central venous pressure, guide fluid therapy
• For measurement of pressures (PA, PCWP)
• Measurement of Cardiac output
• Diagnosis of shunts
• Tests of drug effectiveness (pulmonary hypertension)

99. CORONARY ANGIOGRAPHY
• Gold standard for diagnosis of CAD
• Through femoral or radial arteries
• Passage of special catheters retrograde into aortic root,
cannulation of the left and right coronanry arteries
• Injection of a radioopaque agent to replace blood
• Xray taken to see the arteries in different views

101. PCI
• After doing CAG if a treatable lesion is found
• A special thin (0.014) inch coronary wire is advanced and the
diseased part crossed
• A balloon is passed over the wire and inflated at the lesion site
to crash the atherosclerotic plaque and expand the artery
• Can be left here but recoil and restenosis common
• A stent is placed at the site
• Bare Metal Stent- BMS (in the past), Drug Eluting Stent- DES
(current practice)

102. PTMC
• Percutaneous valvotomy- commonly done for mitral stenosis
• Commonly through femoral vein
• Septal puncture done with a special needle to cross from the
right atrium to left atrium
• Septum will be dilated after putting a special wire into LA
• Balloon in deflated position is passed over the wire and pushed to
cross the mitral valve an enter LV
• It will be placed across the narrowed valve and inflated which
results in tear of the mitral commissure and widening of the valve

103. PPI
• In patients with symptomatic bradycardia
• Single chamber (ventricles only) or dual chambers (atrium and
ventricle)
• Leads are placed inside the cardiac chambers- through cephalic
vein, axillary or subclavian vein
• Fixed at appropriate sites
• Connected to the pulse generator which is placed in a subcutaneous
pocket made just below the clavicle
• Battery usually lasts for 10 years and may need to be replaced
after that

104. Device closure
• In selected patients with congenital defects which are
clinically significant
• ASD, VSD, PDA
• A special devise passed retrogradely through the femoral
artery or vein
• Positioned inside the defect
• Released sequentially at distal and proximal sites with its
waist occluding the defect

105. Thank you