Select diagnostic catheter, M Vidovich

1. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Catheter Selection and Tricks
for Successful Angiography
Mladen I. Vidovich, MD, FACC, FSCAI
Chief, Section of Cardiology, Jesse Brown VA Medical Center
Associate Professor of Medicine, University of Illinois at Chicago
Chicago, IL
AIM RADIAL
Thursday, September 22, 2016
Budapest, Hungary

2. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Disclosure Statement of Financial Interest
Grant Support/Research Contract:
• Tryton Medical
• Sanofi Aventis
• VA Cooperative Study
Consulting Fees/Honoraria/Speakers Bureau:
• Merit Medical
• St. Jude Medical
• Eli Lilly
• Astra Zeneca
• Boston Scientific
Equity Interests: None
Royalty Income/Intellectual Property Rights: Merit Medical
Salary/Salary Support/Employee: None
2
Within the past 12 months, I have had a financial interest/arrangement or
affiliation with the organization(s) listed below.

3. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Radial Angiography
Diagnostic Catheter Selection
• Overview of clinical considerations
• Catheter options
• Diagnostic challenges
• Ventriculography
• Future

4. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
DIAGNOSTIC
CATHETER
CHOICE
Right vs.
Left Radial
Access
Age
Height
Weight
Previous
CABG
STEMI
Power
Injector

5. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
DIAGNOSTIC
CATHETER
CHOICE
Radial
Artery
Occlusion
Radiation
Peripheral
Cost
Inventory
Spasm
Complications

6. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Diagnostic Catheter
“Philosophy"
Judkins-
Style
Amplatz-
Style
Universal

7. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Right vs. Left Radial Access
RRA
• Universal Catheter
– Tiger
– Jacky
– Sarah
– Other manufacturers
• Judkins
– JL 3.0
– JL 3.5
– JR 4
LRA
• Judkins
– JL 4
– JR 4
• (Universal Catheter)

8. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
RRA/LRA Worldwide
Bertrand OF et al., JACC Cardiovasc Intv 2010; 3: 1022-31
Vidovich MI et al., Cardiovasc Revasc Med 2015; 16: 109-15

9. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Universal Diagnostic Catheters
LEFT RIGHT

10. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
TIGER Diagnostic - LEFT

11. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
TIGER Diagnostic - RIGHT

12. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Diagnostic Catheters
Terumo Optitorque™

13. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Jacky – Tiger
“Amplatz” + “Judkins”

14. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Tiger or Jacky?
TIGER
• “JL 3.5”
• ”dedicated conus catheter”
• Points “up”
• Great for up-going grafts
• Bad for down-going grafts
(RCA)
• Performs best in small aorta
JACKY
• AL 1
• Points horizontal
• Dives deep into RCA
• Great for anterior vessels
• Great for big aortas
• Bad for up-going LM

15. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Judkins Diagnostic Catheters
Yang and Lee. W-tri.org
JUDKINS LEFT JUDKINS RIGHT

16. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Multipurpose
Non-Amplatz Non-Judkins
Yang and Lee. W-tri.org

17. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Age
Tortuous Right Subclavian Artery
• Tortuosity
– Increases distance from radial artery to coronary
ostia
– Negatively affects torque transmission
• Left subclavian atherosclerosis >> right

18. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Subclavian Tortuosity
Author/year N RIGHT LEFT
Hu, 2014 1400 1.4% 0.7%
Freixa, 2012 100 32% 6%
Norgaz, 2012 61 10% 7%
Sciahbasi, 2011 1540 16% 8%
Kanei, 2011 189 2% 0%
Fernandez-Portales, 2006 351 6% 0.6%
Kawashima, 2004 437 11% 0%
Hu et al., Clin Interv Aging 2014; 9: 963-8
Freixa et al. Catheter Cardiovasc Interv 2012; 80:267-272
Norgaz et al. Catheter Cardiovasc Interv 2012; 80: 260-4
Sciahbasi et al. Am Heart J 2011; 161: 172-9
Kanei et al. Am J Cardiol 2011; 107: 195-7
Fernandez-Portales et al. Rev Esp Cardiol 2006; 59:1071-4
Kawashima et al. Catheter Cardiovasc Interv 2004; 61: 333-7

19. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
“Telescoping” technique
• 2 basic principles
– Long sheath
– “Modified” guide catheter
• Improved torque
• Straightened subclavian
• Reduced radiation
exposure
Frangos and Noble, Cardiovasc Med 2011;14(11):315-24

20. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

21. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

22. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

23. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
TORTUOUS RIGHT SUBCLAVIAN
SHORT
ASCENDING
AORTA

24. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

25. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

26. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

27. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

28. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Height
• Problem…
– 6’4” = 193 cm
– Distance from wrist: RRA > LRA
• Solution…
– 110 cm diagnostic catheters
– 125 cm multipurpose catheters
– Telescoping “straightens” subclavian

29. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Weight
• Obesity
– Diaphragm moves cephalad
– Heart axis horizontal
– Short ascending aorta
– Counterclockwise rotation of coronary ostia
• RCA more anterior take-off
• Solution…
– JL 3 diagnostic catheter

30. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Previous CABG
RRA
• Universal Catheter
• Bartorelli-Cozzi catheter
• JR 4
• Multipurpose
• AL 1
LRA
• Judkins catheters
• LIMA catheter

31. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
LIMA
Burzotta F. et al CCI 72(2);263-272, 2008.
Warner JJ, Gehrig TR, Behar VS. CCI 59(3):361-5, 2003.

32. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
LIMA
Bartorelli-Cozzi Catheter

33. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
RIMA
Cozzi S. et al. CCI 2000;50(3);371-374.
LIMA BC

34. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
SVG
RIGHT RADIAL APPROACH LEFT RADIAL APPROACH
BLACK HOLE (AMPLATZ, SBS/XB/EBU, HOCKEY STICK)
AMPLATZ, KIMNY, JL, MP
JR4, MP, AMPLATZ

35. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Radial Artery Diameter (mm)
European Population(s)
0
5
10
15
20
25
30
35
40
45
50
<2.1mm 2.1-2.4mm 2.5-2.7mm 2.8-3.1mm >3.1mm
Radial Artery Size (ultrasound)
2.9 mm ± 0.6 mm
%
5 F r 6 Fr 7 Fr 8 Fr
Y. Louvard, unpublished, web access

36. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Radial Artery Diameter (mm)
Indian Populations
1.8 1.8
1.9
1.8
1.7 1.7 1.7
1.6
0
0.5
1
1.5
2
2.5
LEFT RADIAL LEFT ULNAR RIGHT RADIAL RIGHT ULNAR
MALE
FEMALE
Chugh SK et al. CCI 82;64-73:2013.
N=2,344

37. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Standard Femoral
Ventriculography Catheters
STRAIGHT ANGLED

38. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
MIV Radial Ventriculogram Catheters:
Dedicated Radial Pigtails
LONG
SHORT
Radial Pigtail
LONG
Long, vertical
aorta
Thin/tall men
Smoker/COPD
Radial Pigtail
SHORT
“Chubby” body habitus
Short, horizontal aorta
Obese women

39. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Crossing the valve SHORT
• The added angulation in
the catheter allows for
controlled rotation in
the aorta
• The catheter can be
directed towards the
left cusp for insertion
into the ventricle

40. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Radial Pigtail SHORT
RAO LAO

41. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Radial Pigtail LONG

42. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Left Atrial Pressure/LA Gram
MIV Short Pigtail

43. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
MIV Radial Brochure

44. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Future Directions
Ideal Radial Diagnostic Catheter
• 4 Fr or smaller ?
• High torque/resistance to kinking
• Integrated “telescoping” catheter ?
• Hydrophilic body ?
• High flow / low whip cathteters with
powerinjector
• Integrated pressure transducer ?

45. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
SUMMARY
DIAGNOSTIC
CATHETER
CHOICE
Right vs.
Left Radial
Access
Age
Height
Weight
Previous
CABG
STEMI
Power
Injector

46. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center

47. Mladen I. Vidovich, MD, FACC, FSCAI
Associate Professor of Medicine
University of Illinois at Chicago Jesse Brown VA Medical Center
Thank you.
Mladen Vidovich, MD
miv@uic.edu