Cohen MG

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Catheter Selection for Transradial Procedures, Right Heart Catheterization

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Cohen MG

  1. 1. ITS 2011Catheter Selection for Transradial Procedures Right Heart Catheterization Mauricio G. Cohen, MD, FACC, FSCAI Mauricio Cohen, MD, FACC, FSCAI Director, Cardiac Catheterization Lab Cardiac Catheterization Lab Associate Professor of Medicine Associate Professor of Medicine
  2. 2. Understanding the Catheter’s CourseRight Radial Left Radial Femoral 2 points of 1 point of 1 point of resistance resistance resistance
  3. 3. TRA: Mechanisms of FailureTotal number of Failures 98/2100 (4.6%)Failure of arterial access Inadequate arterial puncture 13%Failure to advance catheter to ascending aorta  Radial artery spasmHydrophylic sheaths not used 34% Radial artery dissection 10% Radial artery loop/tortuosity 6% Radial artery stenosis 1%Failure to complete PCI due to lack of guide support Subclavian tortuosity 18% Inadequate guide backup support 17% n=2,100 Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
  4. 4. Catheter selection – why Standard femoral Dx catheters may be used as well as several other universal curves Learning curve Single vs. Double catheter technique Judkins: JL3.5 and JR4 or 5 Single catheters: – Jacky, Tiger, Sarah, Kimny, Fajadet TRA PCI Right: JR4 or 5 – Left: EBU 3.5 Single Catheter Technique: Ikari L
  5. 5. ITS 2011Catheter Selection: Femoral vs Radial Radial access requires the use of finger-based torque movements instead of the wrist-based used in femoral access Catheter Manipulation Catheter Manipulation Technique Transradial approach can involve more tortuosity than the femoral Transradial approach can involve more tortuosity than the femoral approach approach TRA necessitating small (finger-based) clockwise and TRA necessitating small (finger-based) clockwise and counterclockwise torquing movements and active catheter holding counterclockwise torquing movements and active catheter holding as there may be multiple friction points in the subclavian and the as there may be multiple friction points in the subclavian and the aorta aorta JL 3.5 Radial JL 4.0 Femoral Different curve mechanics, sizing and backup support
  6. 6. Catheter selection - Radial vs. FemoralRadial Hinge Femoral Femoral Radial Ikari Y, et. al. Journal of Invasive Cardiology 2005
  7. 7. ITS 2011 Transradial Curves for Left Coronary – Judkins Left Standard curve for the left coronary artery (may be particularly useful for short left coronary arteries) Sizing suggestions:Downsize the curve by 0.5 from what is used Judkins engagement technique, similar to for a femoral approach femoral approach. Very fine torquing movements may be required to direct the catheter toward the left coronary artery
  8. 8. ITS 2011 Transradial Curves for Left Coronary – Extra Backup Transradial Curves for Left Coronary – Extra BackupWorkhorse curve for left coronary artery Sizing suggestions: JL3.5 = EBU3.5 JL4.0 = EBU3.75 Comparable to: Cordis: XB, XBLAD Apply torque to point the tip to the left coronary cusp BSC: Muta Left, Radial Curve, and turn catheter. Pull wire back and the catheter will Brachial Curve engage the left coronary artery. Backup support from the sinus of valsalva
  9. 9. ITS 2011Transradial Curves for Left Coronary – EBUTransradial Curves for Left Coronary – EBU
  10. 10. ITS 2011 Single Catheter Solutions for Diagnostic CatheterizationTerumo’s OptitorqueDiagnostic CatheterAvailable in 5F and 6F Amplatz shape tip Tiger Jacky Rarely coaxial, good for Amplatz type tip (to RCA, the tip tends to address engagement point superior issues), better suited for LV
  11. 11. Jacky Catheter: Selective Engagement ofRCA and LM
  12. 12. IKARI Left Catheter
  13. 13. IKARI Catheter vs. Standard Catheters Ikari Y, et. al. Journal of Invasive Cardiology 2005
  14. 14. IKARI Left Catheter: MultivesselIntervention
  15. 15. ITS 2011 Transradial Curves for Right Coronary – Judkins RightStandard curve for right coronary artery (may be particularly useful for inferior takeoffs) Sizing suggestions: Same as femoral approach Comparable to: Judkins engagement technique, similar to femoral approach. Apply a clockwise Cordis: Judkins Right rotation to engage right coronary artery BSC: Judkins Right
  16. 16. ITS 2011Transradial Curves for Right Coronary –Judkins Right Deep intubation of RCA with JR4
  17. 17. ITS 2011Universal Transradial Curve – MAC3030
  18. 18. ITS 2011Considerations for Using 5FGuide Catheters 5F guide catheters offer several advantages in radial access procedures Miniaturization of products allow 5F use Small radial arteries may not be suited for 6F guides Less spasm, less patient discomfort Lower incidence of radial vessel occlusion Less contrast/ injection = less nephrotoxicity
  19. 19. ITS 2011New Guiding Catheter TechnologiesHydrophylic Sheathless Catheters- 7.5 Fr Catheter: OD < 6 Fr Sheath- 6.5 Fr Catheter: OD < 5 Fr Sheath Mamas MA et al, CCI 2008;72:357–364
  20. 20. Sheathless Technique with RegularCathetersA 5-Fr diagnostic catheter insertedinto and through a 7-Fr guidingcatheter and over a 0.035 inchstandard J-tip From AM, Gulati R, et al. CCI 2010; 76:911–916
  21. 21. Diagnostic Catheters for PCI?
  22. 22. Conclusions Find the catheter that works best for you – Practice makes perfect Consider starting with Judkins and transition to single Consider starting with Judkins and transition to single technique once confident. catheter technique once you feel more confident. Guiding catheter engagement and support represent significant barriers to transradial procedural success catheter cannulate Keep the guidewire in the catheter until you cannulate Knowledge of guide catheter selection and technique enable successful PCI Complex PCI is achievable with existing equipment ablation CTO, bifurcations, rotational ablation TR specific guiding catheters may offer advantages Dedicated sheathless guiding catheters available outside of US, but sheathless is possible with available equipment.
  23. 23. Access Technique Place an IV in the holding area and exchange over the wire IV wire Apply tourniquet, inject contrast in the artery and wait for contrast in the artery and wait for the venous phase to stick Use real-time ultrasound
  24. 24. Right Heart Catheterizationvia Antecubital Vein
  25. 25. Right Heart Catheterizationvia Antecubital Vein
  26. 26. Right Heart Catheterizationvia Antecubital Vein
  27. 27. ITS 2011Universal Transradial Curve –MAC3030  for  Single catheter for diagnostic interventional and interventional procedures The catheter is pulled back into The catheter is pulled back into the aorta to document a the aorta to document a pullback gradient across the pullback gradient across the aortic value aortic value Angled Tip The RCA ostium is engaged The RCA ostium is engaged with gentle clockwise torque as with gentle clockwise torque as the catheter is slowly advanced the catheter is slowly advanced into the right coronary cusp into the right coronary cuspThe internal lumen of the MAC3030 facilitates The catheter is removed from The catheter is removed fromits use in all coronary interventions the RCA ostium by pulling back the RCA ostium by pulling back while using counterclockwise while using counterclockwise torque and is placed in the left torque and is placed in the left main ostium main ostium
  28. 28. Transradial Curves for Right ITS 2011 Coronary - Other RRAD Easy Radial RightComparable to: Comparable to:Cordis: Hockey Stick Cordis: RB MP (Saito Technique), BRC * Available with long and short tip MRESS Comparable to: Cordis: Barbeau
  29. 29. ITS 2011Transradial Curves - Multipurpose Multipurpose* MRADIAL* Comparable to: Cordis: RB BSC:Kimney Left: MBI/MP2 Right: MPST
  30. 30. ITS 2011 Transradial Curves - Multipurpose ALR12* ALR12* Comparable to: Comparable to: Cordis: Castillo Cordis: Castillo Hockey Stick* Hockey Stick*Comparable to:Cordis: Hockey Stick

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