Catheter selection for transradial angiography and intervention

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2 Catheter selection for transradial angiography and intervention Sandeep Nathan, MD, MSc, FACC, FSCAI Assistant Professor of Medicine Director, Interventional Cardiology Fellowship Program Director, Interventional Cardiology Research & Education University of Chicago Medical Center Chicago, IL

3 Disclosures Consulting / Honoraria Medtronic, Inc. Boston Scientific Volcano Daiichi Sankyo Janssen Grant support Accumetrics, Inc Equity None

4 Mechanisms of TRA failure Total number of Failures 98/2100 (4.6%) Failure of arterial access Inadequate arterial puncture 13% Failure to advance catheter to ascending aorta Radial artery spasm 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:

5 Catheter course: radial vs. femoral Femoral Right Radial 1 point of resistance 2 points of resistance

6 Catheter course: radial vs. femoral Femoral Left Radial 1 point of resistance 1 point of resistance

7 Catheter selection: Initial considerations Learning curve: L radial vs. R radial Single vs. Double catheter technique Judkins: JL3.5 and JR4/5 Single catheters: Jacky, Tiger, Sarah, Kimny, Fajadet TRA PCI Right: JR4 or 5 Left: EBU 3.5 Single Catheter Technique: Ikari L, MAC, AL

8 Catheter selection: The basics The Basics Standard size JL4.0 for access from left arm Size down ½ size for access from the right arm (+/ left arm) Finger torque technique Guide manipulation requires small torquing movements (clockwise and counterclockwise). A fingertip technique is recommended as opposed to the wrist technique that is utilized with the femoral approach Keep it Simple Standard guide catheter shapes work very well in the radial approach JL4.0, JL3.5, JR4, JR5, EBU3.5, MAC

9 Catheter selection: Other considerations High probability of FFR, IVUS/OCT, PCI = start with a universal guiding catheter In the event of a small radial artery / spasm, it s best to use 5 Fr and minimize number of passes through the arm High probability of subclavian tortuosity / distortion (advanced age, PAD, aortic dilatation/aneurysm, thoracic anomalies such as scoliosis, pneumonectomy, etc.) usually favors L radial approach with appropriate catheter selections Large pannus, inability to bring in / slightly pronate L arm usually favors R radial approach with appropriate catheter selections

10 Considerations for intervention Small artery size rarely restricts interventional device options 6 Fr guides allow for most complex procedures: Catheter Size Devices Techniques 5 Fr 6 Fr 7 Fr Balloons < 5 mm Stents < 4.5 mm IVUS Rotablator 1.25 mm All Coronary balloons All Coronary stents Cutting Balloon Rotablator < 1.5 mm Protection device Guideliner JoStent Rotablator 1.75 mm Guideliner No Kissing Balloon Kissing Balloon Simultaneous Kissing Stent 8 Fr Rotablator 2 mm Trifurcation stenting

11 Right radial: Approach, contact points, engagement and support Subclavian tortuosity Height of asc. aorta / pt. stature Aortic dil. / degree & point of contact Coaxiality, degree and angle of vessel intubation JL 3.5 Radial Different curve mechanics, sizing and backup support JL 4.0 Femoral

12 Judkins L catheter R radial approach 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 Angle of approach is often from below ostium (rather than dropping in from above with femoral approach)

13 Judkins R catheter R radial approach Standard curve for right coronary artery (may be particularly useful for inferior takeoffs) Sizing suggestions: Same as femoral approach Judkins engagement technique, similar to femoral approach. Apply a clockwise rotation to engage right coronary artery

14 Universal catheters Tiger Rarely coaxial, good for RCA, the tip tends to point superior Jacky Amplatz type tip (to address engagement issues), better suited for LV

15 Universal catheters 6 Fr Jacky - LMCA 6 Fr Jacky - RCA

16 Merit Medical diagnostic catheters Ultimate 1 Ultimate 2 Cobra C1 Cobra C2

17 Engaging bypass grafts from the wrist

18 Engaging bypass grafts from the wrist Non-torque right catheter (NTR) IMA-like primary curve Soft, reverse secondary curve Tertiary curve is a counter-clockwise spiral (as you look down the catheter from the tip) Useful for engaging anteriorly angulated bypass grafts (including LIMAs from the L radial approach and RIMAs from the femoral approach)

19 Accessing the IMA from ipsilateral approach IMA catheter

20 Accessing the difficult to reach IMA VB-1 catheter A: VB-1 6 Fr diagnostic catheter. B: VB-1 6 Fr guiding catheter. Warner JJ, et al. Cathet Cardiovasc Intervent 2003;59: Right radial approach Right femoral approach

21 Accessing the LIMA from R radial R radial access, Cobra C2 over 145 cm Wholey wire R radial access, in x 190 cm PT2-MS through Cobra C2 Cobra C2 advanced past IM os, withdrawn slightly, rotated counterclockwise

22 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JL 3.5 diagnostic catheter

23 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JL 3.5 diagnostic catheter 6 Fr JL JR4 diagnostic catheter

24 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr JR4 diagnostic catheter 6 Fr IMA diagnostic catheter

25 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr NTR diagnostic catheter

26 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 6 Fr LARA guide catheter 1.25mm followed by 1.5mm rotational atherectomy burr RCA after rotational atherectomy 6 Fr LARA guide, x 300 cm Terumo RunThrough guidewire exchanged for a 300 cm RotaSupport wire, 1.25 mm then 1.5 mm burrs (total 4 runs / 20 passes)

27 Putting it all together: Native coronaries + grafts + complex PCI from the wrist 69 y.o. man with a history of CABG (LIMA LAD, SVG RCA, SVG OM1), EF 20%, severe PVD pre-op for surgical lower extremity revascularization, new inferior ischemia on MPI 3.0 mm DES x 2, 20 ATM deployment, post-dilatation with NC balloon (24 ATM)

28 Guide catheter considerations Intervention with 5 or 6 Fr guiding catheters may require periodic deep catheter engagement for stent deployment Guide catheters EBU 3, 3.5 XB 3, 3.5 JL 3, 3.5, 4 JR 4 Hockey stick Barbeau Kimny MAC 3, 3.5, 4 Mann internal mammary MUTA left MUTA right Radial

29 Guide catheter choices Left system Right system Comparable to Voda, XB

30 Guide catheter choices: EBU 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

31 Guide catheters: Other L system curves LARA Easy Radial Left * * Available with long and short tip

32 Guide selection: L system guides

33 Guide catheters: Other L system curves MRADIAL Comparable to: Cordis: RB BSC: Kimney

34 Guide catheters: Multi Aortic Curve (MAC) Sizing suggestions: Lateral takeoff/small root = MAC30 Superior takeoff/small root = MAC35/40 Superior takeoff/large root = MAC40 Lateral takeoff/large root = MAC45/40 Comparable to: Cordis: BRC (Block Technique) BSC: Radial Curve, Brachial Curve

35 PCI RCA: KR4 H/S guides for TR intervention

36 Universal guide catheters ALR12 Comparable to: Cordis: Castillo

37 Universal guide catheters MAC 30/30 Angled Tip

38 Terumo Ikari guide catheters

39 Terumo Ikari guide catheters Ikari-L for LMCA

40 Terumo Ikari 3.5 L for multivessel PCI

41 Sheathless guide technique 6 Fr Terumo Glidesheath 6 Fr Cordis 110 cm MPA1 diagnostic through Medtronic 7 Fr 100 cm Launcher RCB guide 6 Fr Medtronic 125 cm MPA1 diagnostic through Medtronic 7 Fr 100 cm Launcher RCB guide

42 Sheathless guide technique Gulati R, et al. CCI 2010; 76:

43 Sheathless 7 Fr access via TR

44 Summary Find the catheter that works best for you Practice makes perfect Consider starting with Judkins and transition to single catheter technique once you feel more confident. Guiding catheter engagement and support represent significant barriers to transradial procedural success Keep the guidewire in the catheter until you cannulate Knowledge of diagnostic and guide catheter selection and technique enable successful and efficient execution of cases Complex PCI is achievable with existing equipment CTO, bifurcations, rotational ablation TR specific guiding catheters may offer advantages