Kaul P - AIMRADIAL 2014 Technical - Guide catheter

3rd
Advanced
Interna>onal
Masterclass
AimRADIAL2014
Chicago,
IL
October
23-‐25
GUIDE
CATHETER
SELECTION
FOR
RADIAL
PCI
Thursday
October
23,
2014,
2:25
to
2:40
pm
Prashant
Kaul,
MD,
FACC,
FSCAI
Assistant
Professor
of
Medicine
University
of
North
Carolina,
Chapel
Hill
Medical
Director,
Chest
Pain
Center
Associate
Director,
Interven>onal
Cardiology
Training
Program

Disclosures
Consultant:
• Cardiovascular
Systems,
Inc
• Cardioxyl
Pharmaceu>cals,
Inc

Outline
1. What
are
the
causes
of
Trans
radial
PCI
Failure?
2. The
ideal
guide
catheter
3. Choosing
the
right
size
4. Choosing
the
right
guide
5. Cases
examples

Mechanisms
and
Causes
of
Transradial
PCI
Failure
98
out
of
2100
Transradial
PCI
procedures
Failure
of
Arterial
Access
Failure
to
Advance
Guide
Failure
to
Complete
PCI
due
to
lack
of
Guide
Support
13%
51%
35%
Inadequate
arterial
puncture
(13%)
Radial
artery
spasm
(34%)
Subclavian
tortuosity
(18%)
Radial
artery
dissec>on
(10%)
Inadequate
backup
support
(17%)
Radial
loop/tortuosity
(6%)
Radial
artery
stenosis
(1%)
Dehghani
P
et
al.
J
Am
Coll
Cardiol
Intv
2009;
2:
1057–64

Guide
Catheter
SelecKon:
General
Points
I
The
Ideal
Guide
Catheter
1. Safe,
sob
>p
with
low
risk
of
os>al
dissec>on
2. Easy
to
engage
os>um
3. Coaxial
engagement
4. Good
backup
support
5. Stable

Guide
Catheter
SelecKon:
General
Points
II
• Leb
vs.
Right
radial
approach
• Guide
Catheter
choices
(size/shape)
• Pick
the
“right”
guide/approach
for
you
• Get
comfortable
with
it

Guide
Catheter
SelecKon:
General
Points
III
• Passive
support:
larger,
s>ffer
guide
– Relies
on
shab
and
>p
shape
to
os>al
engagement
• Ac>ve
Support:
deep
intuba>on
– Uses
contralateral
aor>c
root
to
maintain
support
• Guide
Extension
(Mother-‐Child
system)
– GuideLiner
(Vascular
Solu>ons,
Inc)
– Guidezilla
(Boston
Scien>fic)
• Other
techniques
– Balloon
Anchoring
– Buddy
Wire

Femoral
vs
Right
RA
vs
LeN
RA
Patel
T,
Shah
S,
Pancholy
S.
Patel’s
Atlas
of
Transradial
Interven>on:
The
Basics
and
Beyond
2012.
FEMORAL
RIGHT
LEFT
At
least
2
points
of
Resistance

RelaKve
Size
5
Fr
2.3
mm
6
Fr
Mean
Radial
Artery
7
Fr
2.5
mm
Inner
Diameter
2.9
mm
ID 8F sheath
OD 8F guide
2.6
mm
±
0.41
mm
1.7
mm
2.0
mm
2.34
mm
2.31
mm
Sheath
Guide
Men:
2.69
±
0.40
mm
Women:
2.43
±
0.38
mm
1.67
mm
1.98
mm
Adapted
from
From
AM,
Gula>
R,
Prasad
A,
Rihal
CS.
CCI
2010.
76:
911-‐916.

The
Role
of
Larger
(≥
7
Fr)
Guides
• More
support,
ID
for
complex
lesions,
larger
devices:
– Chronic
Total
Occlusions
– Bifurca>on,
kissing
balloon,
2
stent
techniques
– Rota>onal
Atherectomy
with
burr
≥
1.75
mm
– JoStent
Grabmaster
Rx
≥
4.5
mm

Backup
Support
of
Regular
Guiding
Catheters
pushing force of the gauge
resistance encountered by a
advancement into a blood
support of the guiding
pushing force of the gauge
catheter disengaged from
small arrow). All meas-urements
measured for the 4-in-5,
systems as well as for the
systems by using the same
child catheter (ST01)
tree model by 0, 1, 5,
arrow) out of the mother
stent delivery system
tree model at a constant
gauge machine (Fig. 1D,
backup support of the
defined as the pushing
mother guiding cathe-ter
ostium (Fig. 1D, small
repeated five times.
Takeshita
S
et
al.
CCI 2012. 80:292–297.
Fig. 2. Backup support of the regular guiding catheters
The backup support of the 5- and 6-Fr guiding catheters was

Larger
Transradial
OpKons
7Fr
Sheath
• Oversized
• Spasm
• Occlusion
Thin
walled
Sheath
• Glidesheath
Slender
• Significant
advance
Sheathless
• Dedicated
systems
• Home
made
systems
✗

Glidesheath
Slender
Initial Experience with the Glidesheath Slender 3
Initial Experience with the Glidesheath Slender 3
Initial Experience Initial Experience with the with Glidesheath the Glidesheath Aminian
A,
et
al.
CCI
2013.
Oct 6. doi: 10.1002/ccd.25232.

Sheathless
Concept
7
Fr
2.9
mm
2.34
mm
2.31
mm
Sheath
Guide
Mean
Radial
Artery
Inner
Diameter
2.6
mm
±
0.41
mm
Men:
2.69
±
0.40
mm
Women:
2.43
±
0.38
mm
Adapted
from
From
AM,
Gula>
R,
Prasad
A,
Rihal
CS.
CCI
2010.
76:
911-‐916.
5
Fr
2.3
mm
OD
7F
guide
<
Average
RAD

Commercial
Sheathless
Guide
System
Courtesy
Rajiv
Gula>
• ID
of
7.5
Fr
guide
• OD
of
6
Fr
sheath
• Tapered
dilator
• Hydrophilic
coated
• Smooth
inser>on,
liqle
spasm
• Tendency
to
slip
• Expensive
Sheathless Eaucath, Asahi Intecc®, Japan

Tapering
a
Standard
Guide
Catheter
for
Sheathless
InserKon
into
the
Radial
Artery
gauge
Men-drel
Intro-ducer
6F GC
Fr
then
200
bolus
pseudo-taper’’
5
912 Variable, Age (yrs) Male gender Diabetes Hypertension Hypercholesterolemia Body mass index Chest pain prior to Preprocedural shock Peripheral vascular Cerebrovascular disease Prior CABG Fig. 1. A 5-Fr diagnostic catheter inserted into and through a
Prior myocardial 7-Fr guiding catheter and over a 0.035 inch standard J-tip
Single vessel disease wire for easier percutaneous insertion of the guiding catheter
Angiographic presence into the radial artery. [Color figure can be viewed in the online
Most severe lesion issue, which is available at wileyonlinelibrary.com.]
B2 C Stents per patient Drug eluting stent Glycoprotein IIb/Select
Cook
Diagnostic Guidewire (Cordis Corporation, Miami,
FL) (2) insertion of a long (125 cm) 5 Fr multipurpose
InfinitiVR Diagnostic Catheter (Cordis Corporation, Miami,
FL) into and through a 6 Fr guiding catheter over a 0.035
5F 125 cm
MPA2
0.035”
J
Wire
• Lack
of
hydrophilic
coa>ng
• Available
in
US,
inexpensive
• Imperfect
transi>on
of
dilator
• “Catch”
on
inser>on
From
AM,
Gula>
R,
Prasad
A,
Rihal
CS.
CCI
2010.
76:
911-‐916.
interventions using a sheathless technique with stand-ard
large bore nonhydrophilic guiding catheters.
TABLE I. Baseline Characteristics
From et al.
8
Fr
guide
6
Fr
125
cm
MPA2
diagnos>c
0.035”
J
Wire

Going
Smaller:
5Fr
Guides
PROS
• Allows
PCI
through
5Fr
Sheath
• Stent
up
to
4.5
mm,
IVUS,
Rotablator
1.25
mm
• Improved
success
with
small
radials
and
difficult
loops
• Less
trauma>c
during
deep
intuba>on
CONS:
• Higher
risk
of
air
trapping/embolism
during
catheter
removal
• Less
op>mal
coronary
visualiza>on
• Complex
interven>ons
and
bulky
devices
not
feasible
• Kissing
balloon
not
possible

Virtual
3
Fr,
Medikit,
Tokyo,
Japan

LAD
OpKons
Table 4. PCI-Guiding Catheters
All U.S. Canada-Europe China India Japan
LAD
Judkins left 22.5 6.3 21.6 20.7 10.0 38.4
XB 3.0 8.1 10.1 7.0 20.7 16.7 0.0
XB 3.5 18.2 26.6 18.9 13.8 6.7 5.8
Amplatz left 1.4 2.5 1.3 0.0 3.3 0.0
Tiger II 0.6 1.3 0.5 0.0 3.3 0.0
EBU 3.5 27.9 35.4 26.9 41.4 50.0 20.9
EBU 3.75 6.5 7.6 7.9 3.4 3.3 5.8
EBU 4.0 5.6 1.3 8.0 0.0 0.0 2.3
Kimny 0.8 2.5 0.8 0.0 0.0 0.0
Fajadet left 0.5 1.3 0.5 0.0 0.0 0.0
MUTA left 0.7 0.0 1.1 0.0 0.0 0.0
Other 7.1 5.1 5.4 0.0 6.7 26.7
Cx
Judkins left 12.5 5.1 11.0 3.4 0.0 26.7
Bertrand
O
et
al.
JACC:Int
2010.
3:
1022-‐31.

EBU 4.0 5.6 1.3 8.0 0.0 0.0 2.3
Kimny 0.8 2.5 0.8 0.0 0.0 0.0
Fajadet left 0.5 1.3 0.5 0.0 0.0 0.0
MUTA left 0.7 0.0 1.1 0.0 0.0 0.0
Other 7.1 5.1 5.4 0.0 6.7 26.7
Cx
Judkins left 12.5 5.1 11.0 3.4 0.0 26.7
XB 3.0 6.5 6.3 4.9 13.8 13.3 1.2
XB 3.5 20.8 30.4 21.3 17.2 20.0 8.1
Amplatz left 10.8 3.8 13.0 10.3 6.7 5.8
Tiger II 0.3 0.0 0.3 0.0 3.3 0.0
EBU 3.5 26.1 26.6 25.1 48.3 43.3 25.6
EBU 3.75 6.2 15.2 6.1 3.4 6.7 7.0
EBU 4.0 8.7 2.5 11.8 0.0 3.3 3.5
Kimny 0.8 1.3 1.0 0.0 0.0 0.0
Fajadet left 0.5 2.5 0.2 3.4 0.0 0.0
MUTA left 0.4 0.0 0.7 0.0 0.0 0.0
Other 6.3 6.3 4.8 0.0 3.3 22.1
RCA
Judkins right 70.2 69.6 70.3 93.1 80.0 48.8
catheter shape—48.6% and 46.8%, respectively. Not
Bertrand
O
et
al.
JACC:Int
2010.
3:
1022-‐31.
LCx
OpKons
Table 3. Diagnostic Catheters
All U.S. Canada-Europe China India Japan
LCA
Judkins left 3.5 44.9 37.8 49.4 25.8 15.2 26.4
Judkins left 4.0 21.6 14.6 23.1 12.9 0.0 35.6
Kimny 1.8 7.3 1.1 3.2 3.0 2.3
Multipurpose 6.2 4.9 4.3 45.2 0.0 11.5
Tiger/Tiger II 16.1 12.2 15.1 12.9 75.8 1.1
Amplatz left 2.2 1.2 2.9 0.0 0.0 1.1
Barbeau 0.2 0.0 0.3 0.0 0.0 0.0
Fajadet left 0.1 0.0 0.0 0.0 0.0 0.0
Other 7.0 22.0 3.8 0.0 6.1 21.8
RCA
Judkins right 4.0 58.8 46.3 64.6 38.7 12.1 52.9
Kimny 1.7 7.3 1.0 3.2 3.0 2.3
Multipurpose 6.7 7.3 4.6 45.2 0.0 11.5

grafts, Judkins right remains the most frequently used
catheter shape—48.6% and 46.8%, respectively. Not
EBU 3.75 6.2 15.2 6.1 3.4 6.7 7.0
RCA
EBU 4.0 OpKons
8.7 2.5 11.8 0.0 3.3 3.5
Kimny 0.8 1.3 1.0 0.0 0.0 0.0
Table Fajadet 3. left Diagnostic Catheters
0.5 2.5 0.2 3.4 0.0 0.0
MUTA left 0.4 0.0 0.7 0.0 0.0 0.0
Other All 6.3 U.6.3 S. Canada-4.8 Europe China 0.0 India 3.3 Japan
22.1
RCA
Judkins right 70.2 69.6 70.3 93.1 80.0 48.8
Amplatz right 10.2 11.4 12.0 0.0 6.7 2.3
Amplatz left 5.8 7.6 5.4 0.0 6.7 10.5
Barbeau 1.9 1.3 2.6 3.4 0.0 0.0
Kimny 1.3 3.8 1.3 0.0 0.0 0.0
Fajadet right 0.4 0.0 0.5 0.0 0.0 0.0
MUTA right 0.2 0.0 0.3 0.0 0.0 0.0
Other 9.8 6.3 7.5 3.4 6.7 38.4
Left SVG
Left bypass graft 19.4 16.5 21.0 24.1 3.3 7.0
Amplatz left 37.3 39.2 36.6 24.1 26.7 62.8
Multipurpose 6.2 8.9 4.8 6.9 30.0 2.3
LCA
Judkins left 3.5 44.9 37.8 49.4 25.8 15.2 26.4
Judkins left 4.0 21.6 14.6 23.1 12.9 0.0 35.6
Kimny 1.8 7.3 1.1 3.2 3.0 2.3
Multipurpose 6.2 4.9 4.3 45.2 0.0 11.5
Tiger/Tiger II 16.1 12.2 15.1 12.9 75.8 1.1
Amplatz left 2.2 1.2 2.9 0.0 0.0 1.1
Barbeau 0.2 0.0 0.3 0.0 0.0 0.0
Fajadet left 0.1 0.0 0.0 0.0 0.0 0.0
Other 7.0 22.0 3.8 0.0 6.1 21.8
RCA
Judkins right 4.0 58.8 46.3 64.6 38.7 12.1 52.9
Kimny 1.7 7.3 1.0 3.2 3.0 2.3
Bertrand
O
et
al.
JACC:Int
2010.
3:
1022-‐31.

Ikari Left Guide Catheters
Ikari
Guide
Catheters
Ikari
et
al.
J
Invasive
Cardiol
2005
;17:636-‐41
A
B

Ikari Right Guide Catheters
Ikari
Right
A
A
B
IR: Ikari Right
Ikari-‐R
Judkins
859*73+.72,0*3+'5(-.3(*4-0.(57*5

Comparison
of
1
Dedicated
Radial
Catheter
Compared
to
2
Radial
Catheters
for
DiagnosKc
and
Coronary
IntervenKon
Revascularization Medicine 14 (2013) 27–31 29
Table 4
Procedural times: Comparison of 1 dedicated radial catheter compared to 2 radial
catheters for diagnostic and coronary intervention.
1 radial catheter
(n=39)
CCL2BT (min) 31 (26:39) 40.5 (37.75:50.25) b0.001
Door-to-Balloon Time (min) 74 (55:95) 95 (77.5:127) 0.041
Puncture time (min) 2 (1:4) 3.5 (2:5) 0.116
Fluoroscopy time (min) 13.9 (10.2:20.6) 20.4 (14.58:30.05) 0.025
Total Procedural time (min) 50 (43:71) 64 (55.75:83.5) 0.065
Values are median times in minutes with inter quartile range in brackets.
CCL2BT=Cardiac catheter laboratory to balloon time.
3.2. Lesion and procedural characteristics
2 radial catheters
(n=14)
P value
Lesion and procedural characteristics are shown in Table 2. Two
Malaiapan Y et al. Cardiovascular Revascularization Medicine 2013. 14: 27–31
patients from the radial cohort crossed over to a femoral approach
because of severe tortuosity of the innominate artery. The crossover

Backup
support
of
the
5-‐Fr
mother–child
system
Fig. 3. Backup support of the 4-Fr mother–child system When the 4-Fr child catheter
was extended 9 cm beyond the tip of the mother guiding catheter, the backup support of
the 4-in-5, 4-in-6, and 4-in-7 systems significantly increased compared with when the mother
guiding catheter was used alone (*P 0.05, †P 0.0001). The 4-in-8 system showed no
significant increase in backup support.
Backup support of the 5-Fr mother–child system
the 5-Fr child catheter was extended #5 cm beyond
of the mother guiding catheter, the backup support
5-in-6 and 5-in-7 systems significantly increased
9 cm beyond the tip of the mother catheter, the backup
support of the 5-in-6 system was significantly greater than
that provided by Takeshita
the 7-Fr S
guiding et
al.
CCI catheter 2012. 80:292–alone 297.
(†P 0.0001),
and it was similar to that obtained with the 8-Fr catheter

Case
• 56
year
old
WF
• CAD
(PCI
to
LAD
2005)
,
HTN,
FHx,
HLD
• Progressive
exeronal
angina
• Resng
chest
discomfort
• Elevated
cardiac
biomarkers
• EKG:
NSR
with
TWI
in
inferior
leads
• Physical
Exam:
– 86/min,
BP
160/90
mmHg
– Euvolemic
– RRR,
no
MRG
– Clear
chest,
No
edema

6Fr
JR4
Guide
Catheter
would
not
advance

disease
atherosclero-sis.
more re-sistant
most
calcific
arteriosclerosis
arterioscle-rosis
stenosis that
from
techniques
operators as
appreciate
trees. If
interventional col-league
interventional
The severity of spasm is a clinical and procedural
Balloon
outcome related Assisted
definition. Tracking
Initial failure (to BAT)
pass
through an arterial region may be a manifestation of
Fig. 2. Assembly of BAT technique. [Color figure can be viewed
in the online issue, which is available at wileyonlinelibrary.com.]
Patel
T
et
al.
CCI
Oct
2013.

correctly, a
threatening
spontane-ously,
oper-ator.
pain
where
iatro-genic
down
patient
in the
disease
atherosclero-sis.
more re-sistant
most
calcific
arteriosclerosis
arterioscle-rosis
that
from
techniques
operators as
appreciate
trees. If
col-league
interventional
chances for
has
cathe-ters
passage
RA and BA Vascular Complexities 3
SPECIFIC ANATOMICAL CHALLENGES
Radial Artery Spasm
Beginning radial operators are often apprehensive
about RA spasm. True RA spasm is not as common as
most interventionalists think and is associated more
commonly with those operator with the least experi-ence.
The overall incidence in experienced hands is
about 5.6%, of which 0.5% patients had severe spasm
[6,14,16,18,25]. A classification of RA spasm is shown
in Table II.
The severity of spasm is a clinical and procedural
outcome related definition. Initial failure to pass
through an arterial region may be a manifestation of
Fig. 2. Assembly of BAT technique. [Color figure can be viewed
in the online issue, which is available at wileyonlinelibrary.com.]
TABLE II. Classification of Radial Artery Spasm
Grade I Mild spasm Minimal pain and/or discomfort along
the course of RA during and/or
immediately after the procedure.
Grade II Moderate spasm Significant pain and discomfort along

Mulple
(1.25,
1.5,
2.0,
2.5,
3.0
CB)
Balloons
Later

Case
Summary
• If
you
have
a
perforaon-‐
do
not
bail
to
the
femoral
• Use
an
0.014”
wire
and
BAT
and
connue
• Catheter
tamponade
will
heal
vessel
by
end
of
the
case
• Use
a
Guideliner
to
improve
your
support
• Consider
balloon
anchoring
to
advance
equipment

Summary
• Mean
RAD
is
approx.
2.6
mm
(6F
OD
=
2.5
mm,
7F
OD
=
2.9
mm)
• Sheath
diameter

Radial
artery
minimizes
RAO
• If
large
bore
is
needed
consider
either
– thin
walled
sheaths
or
– a
sheathless
technique
(negoate
the
transion)
• Choice
of
Guide
Catheters
• Pick
one
and
get
comfortable
• Negoate
Radial/Brachial/Subclavian
Loops
• Learn
when
to
bail
to
a
different
access
route
« Use
fingers
not
wrist
for
catheter
manipulaon
« Maintain
the
0.035”
wire
in
catheter
during
manipulaon

3rd
Advanced
Internaonal
Masterclass
AimRADIAL2014
Chicago,
IL
October
23-‐25
GUIDE
CATHETER
SELECTION
FOR
RADIAL
PCI
Thursday
October
23,
2014,
2:25
to
2:40
pm
Prashant
Kaul,
MD,
FACC,
FSCAI
Assistant
Professor
of
Medicine
University
of
North
Carolina,
Chapel
Hill
Medical
Director,
Chest
Pain
Center
Associate
Director,
Intervenonal
Cardiology
Training
Program

Kaul P - AIMRADIAL 2014 Technical - Guide catheter

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Kaul P - AIMRADIAL 2014 Technical - Guide catheter