Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
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
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
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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)
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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
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10. PARTS
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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
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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
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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
22. ■ TIP: Tapering tip for
Diagnostic catheters
■ HUB: Metal or plastic, larger
than catheter, tapered hubs –
easier insertion of guidewire.
TIP & HUB
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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
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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
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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
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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)
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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
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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.
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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
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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
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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.
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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
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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
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)
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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
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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
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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
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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
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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
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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
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IMVB-1
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
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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
