Select guiding catheter, MG Cohen

1. Select Guiding Catheter
Mauricio G. Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Associate Professor of Medicine

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support Edwards Lifesciences
Consulting Fees/Honoraria Abiomed / Terumo Medical / Medtronic /
Merit Medical
Major Stock Shareholder/Equity None
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

4. Most Frequently Used Diagnostic Coronary Catheter Shapes
LCB RCB
Amplatz LeftJackyTiger
Judins Right Multipurpose A2 IM IM VB-1Judkins Left 3D LIMA

5. Femoral and Radial Are Different

6. Most Commonly Used Left Guide
Catheters

7. Catheter selection - Radial vs. Femoral
Radial
Femoral
Ikari Y, et. al. Journal of Invasive Cardiology 2005
Radial
Femoral
Hinge

8. Most Commonly Used Right Guide
Catheters

9. Comparison of Backup Force in TRI
JR IR AL IL
0
20
40
60
80
100
120
140
160
JR4 IR1.5 AL1 IL3.5
maxresistance(gforce)
C DA B

10. Guide Catheter Preference for Native
Coronary Arteries during TRA
Coronary Interventions
46.2
22.5
8.1 6.5
16.7
0
10
20
30
40
50
60
70
80
XB/EBU
3.5
JudkinsL
XB3.0
EBU3.75
Other
%ofoperators
70.2
10.2
5.8
13.8
JudkinsR
AmplatzR
AmplatzL
Other
Left Anterior Descending
Left Circumflex
Right Coronary 61.4
12.5 10.8
14.8
EBU/XB
JudkinsL
AmplatzL
Other

11. Pattern of coronary
grafting
Suggested
primary
approach
Comments
LIMA Left Radial
Documented facilitation compared
to femoral approach
LIMA + RIMA
Right Radial or
Femoral
Avoid contralateral cannulation in
severe atherosclerosis of the aortic
arch and subclavian arteries
LIMA + RIMA + RA Femoral
LIMA + SVG(s) Left Radial
Consider aortography to visualize
SVGs and facilitate catheter
selection
SVG(s)
Right Radial or Left
Radial
Left radial easier, specially during
the learning curve
Burzotta F et al. CCI 2008;72:263-272
TRA in Patients with Grafts

12. Judkins Right or Multipurpose
Amplatz Left or Tiger (Judkins left or Multipurpose from left TRA)
Amplatz left, Hockey Stick, Extra backup
Right
TRA
Left
TRA
Burzotta F et al. CCI 2008;72:263-272
Coronary bypass grafts

13. Guide Catheter Preference for
Engagement of SVGs
37.3
31
19.4
6.2 6
0
10
20
30
40
50 AmplatzL
JudkinsR
LCB
Multipurpose
Other
%ofoperators
39.6
29.2
20.8
3.5
6.9
JudkinsR
Multipurpos
e
AmplatzL
LCB
Other
Right SVG
Left SVG

14. Guiding Catheters and Device Compatibility
Catheter Device Kissing
balloon
Kissing
Stents
5F Balloon ≤ 5 mm No No
Stent ≤ 4.5 mm
Intravascular ultrasound
Rotational atherectomy (1.25 mm burr)
6F All balloon sizes Yes No
All stent sizes
Intravascular ultrasound
Optical coherence tomography
Rotational atherectomy (1.5 and 1.75 mm burr)
Aspiration thrombectomy catheters
Embolic protection devices for SVG interventions
Catheter extensions (Mother-Child / GuideLiner)
7F Rotational atherectomy (> 1.75 mm burr) Yes Yes

15. ITS 2011
Considerations for Using 5F
Guide Catheters
• 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
5F guide catheters offer several advantages in radial access procedures

16. ITS 2011
New Guiding Catheter Technologies
Hydrophylic 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

17. Sheathless Technique with Regular
Catheters
A 5-Fr diagnostic catheter inserted
into and through a 7-Fr guiding
catheter and over a 0.035 inch
standard J-tip
From AM, Gulati R, et al. CCI 2010; 76:911–916

19. Most Commonly Used Guiding Catheter Shapes For The Left And Right Coronary Arteries
Extra Backup
(XB – EBU -
Voda)
Judkins
Right

20. ITS 2011
Transradial Curves for Left Coronary –
Judkins Left
Judkins engagement technique, similar to
femoral approach. Very fine torquing
movements may be required to direct the
catheter toward the left coronary artery
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
for a femoral approach

21. ITS 2011
Transradial Curves for Left Coronary – Extra Backup
Workhorse curve for left coronary artery
Sizing suggestions:
JL3.5 = EBU3.5
JL4.0 = EBU3.75
Comparable to:
Cordis: XB, XBLAD
BSC: Muta Left, Radial Curve,
Brachial Curve
Apply torque to point the tip to the left coronary cusp
and turn catheter. Pull wire back and the catheter will
engage the left coronary artery. Backup support from
the sinus of valsalva

22. Transradial Curves for Right Coronary
Judkins Right
Standard curve for right coronary artery
(may be particularly useful for
inferior takeoffs)
Sizing suggestions:
Same as femoral approach
Comparable to:
Cordis: Judkins Right
BSC: Judkins Right
Judkins engagement technique, similar to
femoral approach. Apply a clockwise
rotation to engage right coronary artery

23. Transradial Curves for Right Coronary
Judkins Right
Deep intubation of RCA with JR4

24. Graft Case

25. Low Hanging Fruit  SVG to OM
6F AL 1 Guide

26. 3.5x18 mm Resolute stents
in ostium and body

27. Patient with CP on Table with ST 
Started with 6F IMA guide, Turnpike catheter, with
Fielder XT, Pilot 50 and Pilot 200

30. Pilot 200 wire exchanged for
Grand Slam first and then BMW

32. Predilated with 2.0x12 mm OTW
Maverick, Stented with 2.5x8 mm
Resolute DES

34. ITS 2011
Transradial Curves for Left Coronary – EBU

35. IKARI Left Catheter

36. IKARI Catheter vs. Standard Catheters
Ikari Y, et. al. Journal of Invasive Cardiology 2005

37. IKARI Left Catheter: Multivessel
Intervention

38. ITS 2011
Transradial Curves for Right Coronary –
Judkins Right
Standard curve for right coronary artery
(may be particularly useful for
inferior takeoffs)
Sizing suggestions:
Same as femoral approach
Comparable to:
Cordis: Judkins Right
BSC: Judkins Right
Judkins engagement technique, similar to
femoral approach. Apply a clockwise
rotation to engage right coronary artery

39. ITS 2011
Transradial Curves for Right Coronary –
Judkins Right
Deep intubation of RCA with JR4

40. Conclusions
• Guiding catheter engagement and support
represent significant barriers to transradial
procedural success
 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
 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.