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Diagnostic catheters for coronary angiography
- 2. History Classification Catheter structure & Materials Femoral Catheters Radial Catheters Cathetrs for IMA & graft 2
- 3. FIRST CARDIAC CATHETERISATION ■ In 1929 ■ Werner Forssmann ■ Rubber catheter ■ Through his own antecubital Vein ■ Upto the pulmonary artery 3
- 4. HISTORY OF CORONARY CATHETERIZATION Selective cannulation of coronory or injection of dye into coronary arteries were considered unsafe ■ Random "Brute Force" Approach – Upto 50 cc contrast in 1-2 sec ■ Phasic injections – electronic pressure injectors timed with cardiac cycle for intentional diastolic injection ■ Methods of reducing cardiac output – Acetylcholine arrest – Elevation of intrabronchial pressure ■ Occlusion aortography ■ Differential opacification of aortic stream 4
- 5. FIRST SELECTIVE CORONARY ANGIOGRAM ■ Was an accident ■ Dr Mason Sones in 1958 ■ After withdrawing a catheter after ventriculogram cannulated the RCA unknowingly ■ When contrast was injected for an aortogram selective opacification of RCA noted ■ Designed Sones catheter and popularized the technique ■ Several preformed catheters were later designed. 5
- 6. DIAGNOSTIC CATHETERS Angiography Pressure monitoring Oxygen saturation monitoring 6
- 7. ANGIOGRAPHIC CATHETERS Flush • No selective canulation of vessel • Contrast injection through multiple side holes • Uniform injection without recoil • Tip usually rounded to avoid entering a vessel and to keep shaft in centre • Ex Pigtal catheter Selective • Selectively canulation of vessel • Rotational stiffness enough to selectively seek a vessel orifice • Enough flexibility to advance into the vessel • Flow rate not important as contrast volume used is less. • Ex – preformed coronary catheters 7
- 8. CORONARY CATHETERS Diagnostic • Thicker shaft • Internal dm Smaller • Tapering tip • Less Reinforced construction ( 2 layers) Guide • Thinner shaft • Internal dm larger • Non tapering tip • More Reinforced construction ( 3 layers) 8
- 9. IDEAL CHARACTERISTICS OF A CATHETER ■ Better Torque Control – Increase Outer diameter – Reinforced construction ■ Pushability – Increase Outer diameter – Stiffer Material – Decreasing overall part length ■ Flexibility – Decrease Outer diameter – Material with less modulus of elasticity – Increasing overall part length ■ Trackability ■ Radio-opacity ■ Atraumatic Tip ■ Low Surface frictional resistance ■ Kink resistance 9
- 10. PARTS 10 A) TIP LENGTH – Increased length offers more stability in target vessel at the cost of maneuverability in the parent vessel. B) PRIMARY CURVE – angle of the target vessel from its parent artery. C) SECONDARY CURVE -- width of the parent vessel. D) TERTIARY CURVE –normal curvature of the parent vessel. E) CATHETER LENGTH – Usually 100 or 110 cm
- 11. Over bent & Under bent catheters Underbent- Angle of catheter tip is larger outside the body than inside ■ Difficult to manipulate, shape difficult to predict ■ Difficult to do deep engagement Over bent- Angle of catheter tip is smaller outside the body, than inside ■ Shape of overbent inside body-easy to predict ■ Easier to manipulate 11
- 12. SIZE MEASUREMENT: FRENCH CATHETER SCALE: The French catheter scale is commonly used to measure the outer diameter of cylindrical medical instruments D(mm) = Fr/3 Most commonly in adults -- Diagnostic Catheters of 5 – 7 Fr size 12
- 13. ■ Thick walled- – Better pushability and torque transmission – Accentuates pressure waveform-systolic overshoot & diastolic dips. ■ Thin walled _ – Improves monitoring, blood sampling & flushing abilities, decrease thrombogenicity. – Disadvantage – less torque control, not suitable for high pressure injection. WALL THICKNESS 13
- 14. 14 CATHETER MATERIALS Angiographic catheters made from Synthetic and semisynthetic Polymers Dacron Nylon Polyvinylchloride (PVC) Polyethylene (PE) Fluoropolymers (PTFE) (TEFLON) Polyurethane (PUR) Silicon Radio opacity by incorporating Ba , Bi , Ir
- 15. CHARACTERISTICS Flexibility & Stiffness (Elastic coefficient) Friction coefficient – Vascular Trauma Thrombogenicity Tensile Strength (Memory) Moisture & Drug absorption Mouldabilty 15
- 16. ■ Very maneuverable & flexible. ■ Covered by polyurethane coating – reduce vascular trauma. ■ Some have Nylon core-increase bursting pressure ■ Nylon – great mechanical & physical strength, reduced friction coefficient – achieve high flow rate of fluids ■ Eg- NIH Catheter , Original Sones Catheter. DACRON 16
- 17. ■ Excellent memory ■ Softer than polyethylene or Teflon – Less vascular trauma ■ Increased thrombogenicity ■ Reshaped if immersed in boling water. ■ Eg – pigtail angiographic (cordis) catheters & original judkins catheters. POLYURETHANE 17
- 18. ■ Stiffness inbetween Polyurethane & Teflon. ■ More Thrombogenic than PVC, polyurethane ■ Heat Mouldablity good ■ Eg – pigtail angiographic catheters, judkins catheters POLYETHYLENE 18
- 19. ■ Softest & flexible among all ■ High friction coefficient- spasm. ■ Increased thrombogenicity. ■ Very poor tensile strength (memory) ■ Cant be reformed. ■ Most hydrophilic. ■ Drugs absorbed- NTG, insulin, diazepam,thiopentone. ■ Eg- Balloon-tip flow directed catheters. POLYVINYL CHLORIDE 19
- 20. ■ Stiffest – no suitable for selective catheters ■ Poor memory. ■ Low friction coefficient. ■ Eg – Brockenbrough catheters, transducer-tip catheters & introducer sheaths. TEFLON 20
- 21. CATHETER LAYERS 21 Outer Layer Reinforcement –usually stainless steel braid Determines torque and Kink resistance Outer coating to reduce friction and thrombogenisity
- 22. ■ TIP: Tapering tip for Diagnostic catheters ■ HUB: Metal or plastic, larger than catheter, tapered hubs – easier insertion of guidewire. TIP & HUB 22
- 23. SIDE HOLES Advantages Prevent catheter damping (occlusion of the coronary ostium) Allow additional blood flow out of tip, to perfuse the artery. Avoid catastrophic dissections in the ostium of the artery Avoids Disengagement during Injections Disadvantages False sense of security because now, aortic pressure, and not the coronary pressure is being monitored. Suboptimal opacification Makes catheter tip weak - kinking at side holes 23
- 24. Catheter Choices 24 Left Catheters •Judkins Left •Amplatz Left Right Catheters •Judkins Right •Amplatz Right •Right Coronary 3D Universal •Multipurpose •Sones •Castillo Universal Radial •Tiger •Jackey •Kimney •Etc.. Graft & IMA Catheters •RCB •LCB •IMA •IMA VB-1
- 25. Catheter choice and size selection Catheter Choice Access Height & weight Age Anatomy of aorta Target vessel Native coronory / post CABG ACS vs Elective Operator 25
- 27. JUDKINS CATHETER ■ Melvin Judkins in 1967 ■ Preformed catheter ■ Primary and secondary curve ■ Tapered tip with end hole ■ Designed for femoral route ■ Little manipulation needed if used from femoral route 27
- 28. JUDKINS CATHETER Size 3.5to 6 by most companies Length 100 cm 4-7 French available Size 4 usually used Right radial access 0.5 less size used for left Coronary 1 larger size for right Coronary In aortic aneurysms heat modification for size 7 to 10 done Curve length = distance between P (primary curve) & S (secondary curve) 28
- 29. ENGAGEMENT ■ Left Judkins ■ Right Judkins 29
- 30. 30
- 31. Aortic width 31
- 32. AMPLATZ CATHETER ■ Original catheter by Kurt Amplatz ■ Austrian Radiologist ■ 1967 ■ Right and Left comes in 3 sizes usually ■ 1 ,2,3 with increasing curvature ■ 0.75 size , increments of .5 and 4 size also available for AL 32
- 33. AMPLATZ LEFT ■ Coronory ostia out of conventional judkins Like high and posterior origin ■ It can selectively canulate LAD or LCX if short left main stem ■ Separate origins of left anterior descending and left circumflex coronary arteries. ■ High anterior right coronary arteries (RCAs) or Shepherd’s Crook RCA. 33 While engaging the left coronary pushing the catheter will cause disengagement and pulling the catheter will cause deeper engagement of the Amplatz catheter, due to its peculiar curve
- 34. AMPLATZ RIGHT ■ Amplatz right coronary catheter can be used to cannulate right coronary arteries with abnormal, usually, an inferior origin or high anterior 34
- 35. Coronary anatomy Variation Coronary ostial location: High Low Anterior Posterior Coronary ostial orientation (take offs): Superior Horizontal Inferior Shepherd’s crook (RCA’s only) 35
- 36. Coronary Ostial take offs Horizontal Inferior Superior Shepard crook RCA 36
- 37. SUMMARY RCA Normal origin And Course JR4 Anterior ectopic origin AR, AL , Hockey stick Inferior ectopic origin with inferior course MP Superior ectopic origin from ascending thoracic aorta with inferior course MP Superior course IM 3DRC Tortuous bend anatomy , posterior takeoff 3DRC Anomalous RCA from left sinus JL 5,6 AR 2,3, LMCA Normal origin and course Jl4 Large ascending thoracic aorta JL 5,6 Small Acsending thoracic aorta JL3 , 3.5 Anomolous origin from right sinus AR Anomolous origin of LCX from right sinus JR AR MP Separate origin of LCX LAD AR 37
- 38. MULTIPURPOSE CATHETER ■ Initial multipurpose catheter by Schoonmaker & King ■ In 1974 ■ Developed to avoid the need of 3 separate preformed catheters for both coronaries and ventriculography from femoral route ■ Similar to the Sones catheter ■ Polyurethane catheter ■ Single curve with straight tip an end hole and two side holes. 38
- 39. MULTIPURPOSE CATHETER ■ A bend – hockey stick with straight tip 120 degree curve ■ B bend -- gradual 90 degree curve ■ MP A-1 : 1 end hole only MP A-2 : 2side holes ,1end hole MP B-1 : 1 end hole only MP B-2: 2 sideholes and an end hole ■ Use: CAG – Both native vessel and graft , Ventriculography , Right heart catheterization ■ With more specialized catheters its use has decreased 39
- 40. Other Catheters 3DRC Castillo Gensini Sones 40
- 41. RADIAL ACCESS More learning curve More radiation to operator Limits guide catheter size 41 Less bleeding and vascular complications Cost effective Patients preference Early discharge Anticoagulants can be continued
- 42. RADIAL ACCESS Standard catheters are all designed to to be used from femoral route High learning curve High Incidence of artery going for spam – hence catheter exchanges should be minimized Subclavian tortuosities, Radial loops, Anomolous High origin of radial artery Sheath and catheter size limitaiton 42
- 43. RADIAL ACCESS ■ Course of catheter 43
- 44. Difficulty passing to aorta 44
- 45. DIAGNOSTIC CATHETERS - RADIAL APPROACH ■ Two catheter – JR & JL – AR & AL ■ Single Catheter – Standard femoral catheters – JL , AL , AR – Universal /Bilateral catheters – Ex: ■ Tiger , Jacky , Sarah (Terumo) ■ Kimney (Boston Scientific) ■ MAC 30-30 ( Medtronic) ■ Ultimate Radial 1 & 2 (Merit medical) ■ Bilateral Brachial (Cordis) 45
- 46. Coronary Speciifc or Universal ?? 46 Advantages • No exchange • Less flouro time Disadvantages • Learning curve • Coaxial engagement difficult – Increased ostial trauma • Inferior take offs – deep seating • Inferior take off RCA – S elective Conus branch canulation
- 47. Tiger & Jacky Catheter ■ Both RCA and LCA with one catheter that can potentially: – Limit catheter exchanges – Shorten procedure and fluoroscopic time – Lower cost per procedure ■ Side hole – Avoids intimal dissection during injection in non coaxial engagement – prevents Kicking off during injections and ■ Available in 5F & 6 F ■ Nowadays used for transradial diagnostics more than any other catheter 47
- 48. 1 side hole Size 4 & 4.5 Length 100 & 110 cm Rarley Coaxial Selective canulation of conus branch can occur 2 side holes Size 3.5 & 4 (Sarah) Length 100 & 110 cm Amplatz type tip Better canulation Ventriculography 48
- 49. HEIGHT ■ Very tall patients 100 cm catheters cannot reach upto coronary ostia ■ Solution – 110 cm Diagnostic catheters – Multipupose catheter with 125 cm – If radial prefer Left Radial access – High radial puncture 49
- 50. WEIGHT ■ Obesity – Diaphragm moves cephalad – Heart axis horizontal – Short ascending aorta – Counter clockwise rotation of coronary ostia – RCA more anterior and LMCA more posterior take off – If radial Left Radial has advantage over right 50
- 51. POST CABG ■ Vessels to tackle LIMA RIMA Grafts (ReSVG or Arterial) 51
- 52. SVG or ARTERIAL GRAFTS ■ Usually Anterior surface higher up from sinus of vasalva ■ Left coronary grafts - left anterior surface with circumflex grafts higher up ■ Right coronary grafts -right anterior surface ■ Ring markers often placed otherwise have to rely on surgeons report and previous angios ■ JR catheter mainstay in graft angios 52 ■ A – dRCA / dLCX ( in L dominant systems) ■ B- LAD ■ C- Diagonal ■ D- LCX / OM / Ramus
- 53. Catheter selection ■ Right Grafts – Primary choice - MP – Alternative – JR , RCB , AL ■ Left Grafts : – Primary Choice – JR4 , AL1 – Upward trajectory may require - LCB , IM , HS – More anterior origin – AL , HS > JR , LCB , MP 53
- 54. BYPASS CATHETERS ■ RCB – Resembles JR4 with a tip curved >90 degree ■ LCB – Primary curve similar to JR4 ( 90 degree ) but secondary curve more acute ( 70 degree) 54
- 55. POST CABG LIMA & RIMA Normal – IM , JR4 Origin from vertical portion of subclavian artery- JR4 , If radial - left radial approach is more suitable in patients with LIMA graft If Both LIMA and RIMA is to be canulated JR4 – can avoid catheter exchange 55 IM LCB
- 56. Internal mammary catheter ■ Resembles Judkins right except for tighter primary curve (80degree) and longer tip 56 IMVB-1
- 57. Other Catheters for IMA ■ BARBEAU ■ RIMA 57
- 58. LIMA CANULATION ■ Ease = Femoral = LRA>>RRA ■ Techniques for LIMA cannulation with IMA catheters from RRA are described ■ All of them based on passing a guide wire upto left elbow and catheter passed over wire 58
- 59. LIMA CANULATION ■ Special Catheters for RRA LIMA also designed ■ Ex: Yumiko Catheter 59
- 60. Right Gastroepiploic ■ Usually to PDA ■ Visceral angiographic catheter like cobra can be used ■ Alternatively JR IMA ■ For angiography non selective injection of coeliac trunk done 60
- 61. SUMMARY Burzotta F et al. CCI 2008;72:263-272 61 Pattern of Coronary Grafting Suggested primary approach LIMA LRA LIMA + RIMA RRA or Femoral LIMA + RIMA + RA Femoral LIMA + ReSVG(s) LRA ReSVG(s RRA or LRA
- 62. THANK YOU 62
Notes de l'éditeur
- Victor S. BeharVictor S. Behar