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06 aimradial2016 thu2 MG Cohen Guiding catheters

Select guiding catheter, MG Cohen

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06 aimradial2016 thu2 MG Cohen Guiding catheters

  1. 1. Select Guiding Catheter Mauricio G. Cohen, MD, FACC, FSCAI Director, Cardiac Catheterization Lab Associate Professor of Medicine
  2. 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
  3. 3. Most Frequently Used Diagnostic Coronary Catheter Shapes LCB RCB Amplatz LeftJackyTiger Judins Right Multipurpose A2 IM IM VB-1Judkins Left 3D LIMA
  4. 4. Femoral and Radial Are Different
  5. 5. Most Commonly Used Left Guide Catheters
  6. 6. Catheter selection - Radial vs. Femoral Radial Femoral Ikari Y, et. al. Journal of Invasive Cardiology 2005 Radial Femoral Hinge
  7. 7. Most Commonly Used Right Guide Catheters
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Most Commonly Used Guiding Catheter Shapes For The Left And Right Coronary Arteries Extra Backup (XB – EBU - Voda) Judkins Right
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. Transradial Curves for Right Coronary Judkins Right Deep intubation of RCA with JR4
  22. 22. Graft Case
  23. 23. Low Hanging Fruit  SVG to OM 6F AL 1 Guide
  24. 24. 3.5x18 mm Resolute stents in ostium and body
  25. 25. Patient with CP on Table with ST  Started with 6F IMA guide, Turnpike catheter, with Fielder XT, Pilot 50 and Pilot 200
  26. 26. Pilot 200 wire exchanged for Grand Slam first and then BMW
  27. 27. Predilated with 2.0x12 mm OTW Maverick, Stented with 2.5x8 mm Resolute DES
  28. 28. ITS 2011 Transradial Curves for Left Coronary – EBU
  29. 29. IKARI Left Catheter
  30. 30. IKARI Catheter vs. Standard Catheters Ikari Y, et. al. Journal of Invasive Cardiology 2005
  31. 31. IKARI Left Catheter: Multivessel Intervention
  32. 32. 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
  33. 33. ITS 2011 Transradial Curves for Right Coronary – Judkins Right Deep intubation of RCA with JR4
  34. 34. 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.

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