Selection of diagnostic catheters in transradial cardiac catheterization

1. Selection of Diagnostic Catheters in
Transradial Cardiac Catheterization
Tak W. Kwan, MD, FAHA, FACC, FACP, FSCAI
Clinical Professor of Medicine
Icahn School of Medicine at Mount Sinai
Executive Chief of the Asian Services Center
Co-Director, Asian Cardiac Services
Senior Associate Director of Cardiac Catheterization
Laboratory and Interventional Cardiology
Mount Sinai Beth Israel, New York City, USA

2. Disclosure
▶ Nothing to disclose

3. Trends of use of r-PCI over time
The proportion of r-PCI procedures accounted
for 6.33% of total procedures (n=178,643),
increasing from 1.18% in the 1st quarter of 2007
to 16.07% in the 3rd quarter of 2012 (P<0.01).
Dmitriy N. Feldman DN et al, Circulation. 2013;127:2295-2306

4. Transradial Diagnostic Catheterization
▶ High quality angiogram
– Successful PCI
▶ Issues
– Puncture site
– Radial spasm, loop
– Subclavian loop, tortuosity
– Aortic arch

5. Areas of resistance
Femoral Approach Left Radial Right Radial
▶ TF and Left radial, only 1 area of resistance
▶ Right radial, 2 areas of resistance, can affect the torque of the catheters.
▶ Different maneuvers need to cannulate the coronary arteries.
▶ Despite 2 areas of resistance, the Right radial is still the preferred access
site.

6. List of Catheters
▶ Left coronary artery
– Judkins Left
– Tiger/Jacky
– Multipurpose
– Amplatz
– Kimmny radial
▶ Right coronary artery
– Judkins right
– Tiger/Jacky
– Multipurpose
– Amplatz
– Kimmny radial
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7. Choices of Diagnostic Catheters
▶ Traditionally industries design catheters for femoral approach.
▶ Differences between right radial, left radial or femoral approches.
▶ Influenced by
– The sites of access (left or right)
– Operators
– Normal or anomalous origin

8. Left Coronary Artery Engagement Using JL3.5

9. Right Coronary Artery Engagement using JR4.0

10. Tiger/Jacky Catheters
 Advantages
 One catheter for LCA,
RCA and LV
Lower cost
 Less manipulation, then
less chance for spasm
 Disadvantages
 Learning curve
 Different manipulation
than standard catheter
(Judkins)
 The catheter is pointing
upward towards the
coronary arteries, avoid
forceful injection
 Sometimes dive deep into
RCA
May insert into Conus
branch of RCA
 Lack of back up support

11. Tiger Catheter
RCA LCA

12. Jacky Catheter
RCA LCA

13. Ascending Aorta Dilatation
Sarah Catheter

14. Different sizes and length of diagnostic catheters

15. High radial puncture in a very tall patient
Tiger 4 (110cm) not reach in standard approach
15
High radial puncture

16. LV Gram
▶ Advance the 0.035” guide-wire in RAO view.
– Make sure the catheter is in higher position to coronary ostium
– Avoid advancing the guidewire into the LM or RCA
▶ Advance the guide-wire into the LV by pulling the catheter up or down or by
rotating it clockwise or counter-clockwise of the catheter.

17. LV GRAM
To avoid staining, always do a test
injection first.

18. Left Coronary Artery
Make a loop of the standard 0.035” guide-wire in the ascending aorta in
AP view.
Advance the catheter over the guidewire.
Remove the guidewire.

19. Left Coronary Artery
▶ The catheter was pulled back gently and rotated gently.

20. Right Coronary Artery
▶ Disengage the catheter from the LCA in the LAO view.
▶ Rotate the catheter clockwise.
▶ Gently push the catheter downward.
▶ Pull back gently and simultaneously rotate clockwise.

21. RCA Cannulation
Catheter is not pushing downward while rotating

22. RCA Conus Branch

23. Left Main Artery is not well engaged. Good engagement after catheter is
pushing downward.

24. Difficult to Enter the Ascending Aorta
Take an angiogram LAO view is very helpful

25. May need a super stiff guidewire

26. Let the guidewire goes into the descending aorta

27. Tiger Catheter/JR
Very helpful to direct to ascending aorta

28. ▶ Place 0.035” wire inside the catheter and torque in case of
severe tortuosity for torque transmission.

29. The loop formed in the guide wire due to marked vascular tortuosity in the
radial approach (A). No significant vascular tortuosity in the left radial approach
(B).

30. Role of 5F Guiding Catheter

31. Summary
Tips of Transradial Diagnostic Catheterization
▶ Angiogram after sheath insertion if felt resistance of guide-wire.
▶ Fluoroscopy in subclavian area to avoid guide-wire inadvertently goes up to
the carotid.
▶ If dilated arch, deep breath can help the catheter drop into the ascending
aorta.
▶ Long 0.035” J guide-wire is helpful, in case for exchange!
▶ May need 0.035” guide-wire inside the diagnostic catheter to torque the
catheter.
▶ Routine cases, no difference between femoral or radial approaches.
▶ Subclavian tortuosity, aortic arch dilatation
– Not obey the law of clockwise or counterclockwise rotation of the catheters
▶ All hand-eye co-ordination
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32. Thank You