Clinical Research Article
Seminar
 

Curriculum in Cath. Lab: Coronary Hardware - Part I
The Choice of Guiding Catheter.
Sundeep Mishra, Vinay K. Bahl
Department of Cardiology, AIIMS, New Delhi, India

 

 

Introduction

Selection of guide catheter is elementary but an issue of extreme importance in performance of percutaneous coronary interventions (PCI). It is often the difference between a successfully executed procedure and a failure. Currently a variety of guiding catheters are available, each with a unique design and construction, which has vastly improved the technique of PCI1-3. Compared to diagnostic catheters, guiding catheters have a stiffer shaft, larger internal diameter (ID), a shorter & more angulated tip (110º vs. 90º), and re-enforced construction (3vs.2 layers). For each given size of guiding catheter, its ID is either a standard, large or giant lumen. In general larger sizes allow for better opacification of the contrast, better guide support and allow pressure monitoring, albeit at a cost of increased risk of ostial trauma, vascular complications and the possibility of kinking of catheter shaft. Larger lumen diameters are mandated when using bulky interventional devices like rotablator, laser, atherectomy catheter, some vascular protection/imaging devices or some special interventional techniques like kissing balloon or kissing stent. Guiding catheters are generally composed of 3 layers. The outer layer consists of either polyurethane or polyethylene for overall stiffness. The middle layer is composed of a wire matrix for torque generation and the inner coating is composed of Teflon for smooth passage of balloon catheter (Fig. 1a). It has generally three curves responsible for its overall unique configuration (Fig. 1b).

Types of Guiding Catheters

Judkins and Amplatz: Guiding catheters are available in several shapes (Fig. 2). However, choosing the right guiding catheter has always been a dilemma. Judkins catheter is extremely useful as a diagnostic catheter because its primary curve is fixed, therefore it intubates only a small segment of ostium of either left main coronary artery (LMCA) or right coronary artery (RCA) and thus carries less risk of trauma to these vessels. However, this same property causes a serious limitation while performing PCI. Since primary curve is fixed, the catheter may not be co-axial with the index artery. Since the catheter makes an angle of nearly 90º with the treated artery, at times it may be difficult to pass balloons and

Figure 1a. Guide catheter construction
 
Figure 1b. Curves in guide catheter
 
other interventional devices. The fixed primary curve is especially disadvantageous in left circumflex (LCX) interventions because the angle may become more, even up to 180º in some cases. On the top of that there is a secondary curve which is long and straight and makes another 90º angle, adding to the difficulty in delivering interventional devices. Furthermore, with Judkins Left (JL), the point of contact on ascending aorta is very high and narrow, increasing the chance of prolapse and dislodgement (3a). On the other hand, there is no point of contact of Judkins Right (JR) with aorta at all providing for extremely poor support provided for performing RCA interventions (Fig. 3b). Ikari et al quantitatively measured the backup force of guiding catheters for the left coronary artery. Three factors were found to be associated with the backup force: catheter size, angle (theta) of the catheter on the reverse side of the aorta and the area of contact made by the catheter on aorta4. The angle (theta) determines the force that can dislodge the guiding catheter.
Correspondence: Sundeep Mishra, Associate Professor, Department of Cardiology, AIIMS, New Delhi, India
E-mail: drsundeepmishra@hotmail.com
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Curriculum in Cath. Lab: Choice of Guiding CatheterS
 
Figure 2. Shapes of guiding catheters
 
 
Figure 3a. Mechanism of support with different type of guiding catheters.
 
Figure 3b. Non-coaxial support provided by Judkins catheter

 

Figure 3c. For tortuous LAD, XB catheter is more co-axial and provides good support
 
Figure 3d. For tortuous LAD, XB - LAD catheter is also more co-axial and provides good support
 
Figure 3e. Hockey Stick guide catheter for

 

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Figure 3f. AL1 guiding catheter provides better support for RCA interventions

 
Figure 3g. Multipurpose guiding catheter is very useful for inferior take-off of SVG graft to RCA.
 
If this angle is small, it results in a greater backup force. Therefore a lower position is preferable as the point of contact on the reverse side of the aorta because the angle approaches 90º. The better guiding support provided by the larger catheter size and larger area of contact on aorta is logical. With Judkins catheter the point of contact is narrow and higher on the aorta contributing to weak back up support. On the other hand with Amplatz Left (AL) type of catheter, base of sweeping secondary curve is intended to rest on the aortic root, providing for additional back-up support. However, this same property makes it prone to dissect the ostium of intubated artery.

Other Guiding Catheters: Long tip guiding catheters like Xtra backup (XB) and Extra back up (EBU) are essentially

Figure 3h. Selection of catheters for saphenous vein grafts. a) MP b) MP or JR or AL c) HS d) HS or AL
 
Figure 3i. LCB catheter for PCI of SVG to obstuse marginal
 
modifications for JL, making them stiffer and with a free primary curve, allowing them to become more co-axial and also provide more support. XB distal tip section lies more horizontal within coronary ostium, sometimes pointing upwards, and intubating more in the LMCA. A longer segment of XB catheter comes in contact with contra-lateral wall of aorta to markedly enhance back-up support. On an average XB catheter provides 67% additional support as compared with JR4. However, this extra-support is at the cost of increased likelihood of trauma to left main, especially if there is already some pre-existing plaque. Furthermore being stiffer there is a larger chance of injury to other branches of vascular tree, particularly if the catheter is not withdrawn over a guide-wire. Thus these catheters are probably not for
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beginners and are best dealt by experienced interventional cardiologists (Fig. 3c). XBLAD is a catheter developed to provide superior support for performing LAD interventions specifically. (Fig. 3d)

Guide Catheter for RCA Interventions: During RCA interventions, JR or Hockey Stick (HS) is usually preferred (Fig. 3e)5,6. If extra-support is required, e.g. chronic total occlusion (CTO) or tortuous lesions, AL1 catheter can be torqued into RCA, while the larger secondary curve rests on the aortic root, gaining additional back-up support, buttressing within the aortic cusp (Fig. 3f). Multipurpose (MP) guiding catheter is especially useful for abnormal take-offs from aorta, especially inferior orientations (Fig. 3g). Three dimensional right curve (3 DRC) catheter is another versatile catheter for tortuous, bent anatomy and posterior or superior take off of RCA. In the Arani catheter, the double angle 90 º curve sits on ascending aorta in S configuration and is therefore useful for RCA with horizontal take-off. The primary and secondary curve provides two contact points on the opposite side of aorta thus providing tremendous back-up support7. However, although Arani catheters provide excellent back up support, because of their straight tip, they are often very difficult to engage. XBR and XBRCA are some new catheters developed specifically for the inferior and superior take off of RCA respectively.

Guide Catheter for LCX Interventions: Due to inherent tortuousity of LCX, interventions on this vessel are sometimes associated with difficulty in guidewire passage and balloon tracking. JL 4 may be gently rotated clockwise to achieve a stable co-axial alignment. If the aortic root is dialted or if JL 4 catheter points anteriorly, JL 5 may be used. Traditionally if additional support is required Amplatz guiding catheters have been recommended. They are also especially useful if there is sharp angulation or abrupt downward origin of LCX from LMCA. AL catheters can sometimes cause deep engagement into LMCA. In that case they should be very carefully disengaged from the coronary artery. Unlike JL catheters a simple withdrawal can cause the tip to advance even further into coronary artery. The best way to disengage an AL catheter is to advance it slightly, to prolapse the tip out of the artery and then rotate it out of the ostium prior to withdrawl8 . The Voda catheter has multiple, non-sharp bends taking contour of aorta providing for a very good support with less catheter manipulation vis a vis Amplatz guide9. In another comparison with JL or AL guides they were found to be as effective as either of them but could be

of particular use when a double angioplasty of the LAD and LCX is attempted during the same procedure10.

Guide Catheter for Saphenous Vein Grafts and LIMA Interventions: For saphenous vein graft (SVG) interventions, JR guiding catheter is usually chosen. However, for abnormal take-offs or abnormal positions of graft, AL1 or MP guiding catheter may be more appropriate (Fig 3h). Alternately, special catheters may be used in difficult cases. El Gamal (EGB) is a pre-shaped catheter with improved distal end-portion for accessing bypass grafts and more precise access of RCA. The extra tip segment is slightly longer which allows it to rest against contra-lateral wall for support. It is useful for delivering bulky devices. Left or Right Coronary Bypass (LCB/RCB) is another preformed catheter which has been found useful in some cases (Fig. 3i). LCB catheter is designed for left coronary venous bypass grafts. Its tip has 90 º bend with 70º secondary bend. It is shaped much like a cobra catheter. RCB catheter is designed for right coronary venous bypass grafts, its tip and secondary bends approximate 120º. It is shaped much like a JR catheter with a shallower tip bend. Multipurpose A-1 may also useful in this situation since it has a straight tip which often falls into right coronary bypass grafts easily. Internal mammary artery (IMA) catheter is designed for both Rt. and left Internal Mammary arteries. It is shaped like a JR catheter but with a steeply angled tip (80 to 85º).

Side Holes versus No Side Holes

Side holes are useful where the pressure gets frequently damped as in RCA interventions, where prolonged intubation of index artery is mandated like CTO interventions or when it is of utmost importance to know the pressure through out the procedure without interruption, for example while performing interventions on sole surviving artery or left main interventions. However, it is not mandated while doing routine left coronary artery PCI or interventions in RCA when use of bulky devices is anticipated. Side holes are mainly useful to prevent catheter damping (occlusion of the coronary ostium). Since the sidehole will admit aortic pressure, it will not be damped. Another benefit of sideholes is that they allow additional blood flow out the tip, to perfuse the artery. Side holes may also help avoid catastrophic dissections in the ostium of the artery if the guide catheter is not co-axial. However, while side holes prevent catheter damping, it can be a false sense of security because now, aortic pressure, and not the coronary pressure is being monitored. The guider can

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still occlude the ostium and the problem will not be identified just watching the pressure monitor. Other problems with side-hole catheters include suboptimal opacification as contrast escapes through side holes, reduction in back up support provided because of weakness of catheter shaft and the kinking at side holes9.

Choice of Guiding Catheters: Depends on the size of aorta, location of ostia on the aorta, the kind of back-up required and whether the artery arises from a normal origin or anomalously, Table 111.

Table 1. Choice of Guiding Catheters

 
Left Coronary Artery:

• Normal Aorta : JL4, AL2, XB 3.5, EBU, Voda

• Dilated Aorta : JL5, AL3, XB4

• Dilated Ectatic Aorta : JL6, AL3, XB4.5

• More Back-up : EBU, XB3.5, Voda, XB-LAD

• Superior Take-off : AL2 ST

• Inferior Take-off : MP A, JL 4 MOD

• High Take-off : AL3, AL4, JL3.5

• Low Take-off : AL1.5

• Posterior Take-off : AL2

• Anamolous CX : MP

Right Coronary Artery:

• Normal Aorta : HS, JR4, AR2

• Dilated Aorta : JR5

• Superior Take-off : AL, AR 2, HS, DA 75

• Inferior Take-off : MP A, HS, AL, AR, JR 4 ST, JR 4 MOD

• High Take-off : AR2, JR 3.5 (0.5 smaller size), RCB, MP

• LIMA

• JR catheter

• Anomalous Origin : JL, HS, 3DRC, AL1, MP, AL2, LCB, JR

• Anterior Origin : AL, MP

• Posterior Origin : AL1, AR 2

• Shepard Crook RCA : AL, LIMA, HS, 3DRC, MP

Saphenous Vein Grafts :

• RCA graft usual location : Primary MP, Alternate JR, AL, RCB, HS, EGB

• RCA graft anterior location : Primary AL, Alternate JR, MP, HS

• LCA graft : Primary JR, HS, Alternate : AL, LCB, MP, EGB

• LCA graft anterior location : Primary AL, HS Alternate : JR, LCB, MP

Left Internal Mammary:

Guide Catheter for PCI of Tortuous Arteries: Tortuous coronary arteries often provide a challenge to the interventional cardiologist. PCI of these lesions is associated with a lower success rate (70-85%) and higher acute complications (up-to 15%)12-15. Tortuousity may be defined as at least 2 or more than 75º bend proximal to the target lesion or at least one proximal bend 90º. Proper selection of hardware, guide catheters, guide wire and balloon catheter is critical for success and safety of these procedures. The pre-requisites for guide catheter is better support, perfect co-axiality, kink resistance and ability to fix the tip of catheter in ostium of intubated artery contributing to a stable position. For LAD interventions XB, or XB LAD is chosen (3c & d). Whereas a Voda or EBU catheter may be appropriate for the LCX interventions.

Guide Techniques for PCI of Tortuous Arteries: Deep Seating of Guide: Deep seating of guide catheter is a technique in which guide catheter is deeply intubated into the artery to be treated. Deep seating can significantly increase the guide support and help deliver angioplasty balloons or stents to the target lesion, both in native coronary arteries and in coronary bypass grafts. Deep seating of RCA or LCX can be accomplished by clockwise rotation and gentle advancing of the guide over the guide wire, whereas counterclockwise rotation is required for LAD (Fig. 4). Another technique is to retract balloon as the guide catheter is advanced and gently rotated clockwise. Extreme care is taken to maintain distal guide wire position and avoid vessel trauma. As soon as the balloon catheter reaches the site of stenosis, the guide catheter is withdrawn to its original position. However, deep guide seating carries a risk of dissection and distal artery embolization especially when used in degenerated SVG. The risk can be minimized by using small size (such as 5 Fr), soft-tip guide catheter and by meticulous attention to maintaining an adequate pressure waveform and to minimizing the length of time that the guide remains deeply engaged.

Child in Mother Technique: Mother and Child Technique is another technique to improve support provided by guide catheter system (Figure 5). It involves 110cm long, 5Fr guide (Child) in 100cm long, 6Fr guide catheter (Mother). Child in Mother could also be 5Fr guide in 7Fr guide catheter 16. It has been estimated that this technique may provide up-to 70% more support. Possible complications associated with Child in Mother technique are either trauma to vessel resulting in dissection or air embolism usually occurring during intubation of child catheter or during angiography performed via the mother guiding catheter.

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Figure 4. Deep seating of MP guide catheter to treat tortuous SVG graft to obstuse marginal. Guide catheter is advanced over mid-portion of SVG using Glide wire.
 
Figure 5 Child in Mother Technique provides much more support than when only a single guiding catheter is used. This technique is especially useful while tackling tortuous lesions
 
Shepard's Crook RCA

Shepard's crook configuration of RCA i.e. a dramatic upturn with a near-180º switchback turn also presents a challenge to the operator. Here crux of the matter is the support provided by guiding catheter. Several studies have shown that PTCA of this morphology is associated with significantly lower primary success rate but similar long-term outcome when compared to PTCA of right coronary arteries without this anatomic variation 8, 17. In view of less support provided and non-coaxial orientation JR is particularly unsuited for this type of RCA configuration. As soon as one attempts to wire the RCA, the guide catheter gets unhooked and thrown off in the aorta. Guide catheters AL1/0.75 and 3DRC are best suited for the anatomy (Fig. 6a&b). The 3DRC guiding catheter is especially useful in this configuration because it is easier to manipulate in the aorta than other RCA guiding catheters (that need to be torqued 180 into position), the

Figure 6a. AL1 catheter for Shepard's Crook RCA
 
Figure 6b. 3DRC catheter provides a better support for performing interventions on Shepard's Crook RCA
 
3DRC shape allows selective coaxial cannulation of the RCA in a very gentle and less traumatic way and there is an excellent contralateral back-up support from the aorta 18 . Other guide catheters that have been used for this condition are Arani 75º, El Gamal, Right Voda and JR4 catheters.

LIMA Interventions

Interventions of LIMA present a special problem to the interventionists. They are not only tortuous but also may be extremely redundant, so that it may be difficult to reach the lesion. The problem of redundancy can be overcome by using longer shaft balloons (150 cm) or choosing brachial or radial approach and shorter guide catheters (90 cm). Difficulty in cannulation of LIMA using femoral approach may be another problem. This problem may arise because of proximal tortuousity of sub-clavian part or acute angle between the proximal sub-clavian artery and the proximal LIMA. This difficulty can be overcome by entering in the left anterior oblique (LAO) 60° projection (as it elongates the aortic arch and allows for excellent visualization of the great vessels). In this projection left sub-clavian artery (LSA) usually originates just distal to the left edge of tracheal air stripe and a gentle counter clockwise rotation of LIMA catheter will result in rapid engagement of LSA. If sub-clavian artery cannot be entered with a preformed LIMA, a JR guiding catheter may

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be used and later exchanged with LIMA catheter. If tortuousity of LSA is extreme and precludes the tracking of guide catheter into LIMA, an ipsilateral brachial or radial approach may be used. Forceful engagement of IMA should be strictly avoided as it is very prone to dissection or spasm. For LIMA engagement, a LIMA catheter is preferred over JR as it is more co-axial (Fig.7). Generally, AP projection is the best view, but if difficulty is encountered shallow RAO 20-30° for the LIMA or LAO projection for the RIMA intervention may help. If still there is a problem it is recommended to intubate in a view which opens up the ostium of LIMA for example LAO 60°. For avoiding spasm, patients should be pretreated with nitroglycerin (NTG) and verapamil. Frequent boluses of NTG 100 µg may be used liberally. If the IMA is small, a 6-7 Fr guide may be useful. After performance of balloon dilatation, it is important to ensure that withdrawal of balloon catheter does not cause the guide catheter to be pulled into origin of IMA because it might cause traumatic dissection of IMA19.
Figure 7. LIMA catheter for LIMA interventions
 

Guiding Catheter Related Complications

The overall complication rates of PCI procedures are higher than diagnostic catheterization20. In patients undergoing PCI, guide catheter related complications pertain to either embolism

 
(air, atheroma or thrombus) or dissection of coronary tree, aorta, abdominal aorta or iliac artery. The incidence of clinically apparent embolization and stroke associated with diagnostic catheterization is less than 1%20. However, the incidence of catheter-related embolism in necropsy studies has been reported to be as high as 30 % 21-22. Air embolism can be prevented by maintaining air free PTCA assembly at all times and performing frequent bleed backs. Guide catheters are generally stiff and large-bore. These design characteristics can be more traumatic to the aorta than diagnostic catheters which are more flexible, have smaller lumens and tapered tips. Keely et al demonstrated aortic debris scraped by the guiding catheter in more than half the cases23. The incidence of atheromatous debris varied with the type of the catheter used (24% to 65%). The JL and MP guiding catheters were associated with the highest amount of aortic debris production, particularly large debris visible at the time of catheter advancement compared to the other guiding catheters evaluated. The JR catheters were the least likely to lead to debris production. The authors postulated that the shapes of the JL and MP catheters are more traumatic to the aorta owing to their long secondary curves, acting as "atherectomy devices" as they pass across friable plaques. Atheromatous embolism during contrast injections can be avoided by allowing sufficient "back bleeding" from the guiding catheter after attaching the Y-connector and each time after the wire removal. Embolism of thrombotic material is another complication encountered during therapeutic procedures. It is important to flush frequently to avoid blood standing in the guide catheter. Guide catheter-induced dissection is an uncommon complication of PCI, but when it occurs, the outcome can be devastating. The exact incidence remains unknown, but numerous case reports of antegradae dissection into coronary artery, retrograde dissection into the aortic root, subclavian or IMA dissection, dissection into abdominal aorta or even the iliac artery are available24. The best way to avoid guide catheter dissection is meticulous attention to technique of guide catheter cannulation and maneuvering the catheter strictly over guide wire while insertion or removal from the body. Amplatz type of guiding catheters and those with side-holes are especially prone to causing dissections. A number of factors are associated with increased risk for coronary artery dissection. Devlin and co-workers demonstrated that majority of LMCA dissections were due to contact of the catheter with the plaque25. This highlights the importance of using catheters that are appropriately sized, positioned and coaxially aligned with the artery. The use of Amplatz-type catheters and performance of PCI in patients with acute myocardial infarction were also associated with guide catheter dissections26 . Other factors that have been proposed include brisk catheter manipulations, vigorous contrast injection, deep intubations of the catheter within the coronary artery, variant anatomy of the coronary ostia, and even vigorous, deep inspiration 27-30. The guide catheter induced dissections can be avoided by using
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appropriately sized and shaped catheters and by avoiding the contrast injection being directed at a plaque. Initial contrast injections should not be forceful until correct coaxial alignment of the catheter has been demonstrated. Contrast should not be injected if the pressure is damped, as this may be due to the catheter resting against a plaque in the artery. Finally, the choice of guide catheter is a risk-benefit tradeoff between extra backup and the possibility of deep intubation and subsequent coronary artery dissection. This decision must be must be made on a case-by-case basis, however, the operator should be aware of the possibility of dissection when using more aggressive guide catheters31.

Guide Catheter Selection for Radial Intervention

The transradial approach to PCI, initially developed by a small group of dedicated pioneers, is now increasingly popular with interventionalists who aim to minimize complications while increasing patient comfort and aim for immediate mobilization32-33. The guide catheter chosen for radial interventions should have several characteristic features to enable a successful outcome of PCI. The catheter should provide optimal stiffness for optimal support, it should have contact on multiple sites of the aortic root, the primary curve of the guide should be flexible, the guide ought to have blunt angles and it should be coaxially aligned with the target vessel. The radial artery is one of the most spasmogenic arteries in the human body. Spasm can be precipitated by mechanical stimuli and so lesser the catheter manipulations, the less risk for spasm34. Various types of catheters are available for left coronary, right coronary and venous bypass grafts. Table 2. Femoral guide catheters are very adaptable to transradial route, JL and JR guide catheters can be used for intubating LCA and RCA, respectively. However, for cannulating LCA, downsizing by 0.5 is appropriate. For RCA interventions AR catheter may be used and AL and MP guides can be utilized for both vessels. When extra support is required EBU, XB, or Voda may be used.

Special Catheters for Radial Route: A range specific guide catheters Fajadet, Kimny, MUTA, IKARI, Barbeau's, new long tip guiding catheters have been designed to give optimum support and alignment35.

Table 2. Choice of Catheters for Interventions via Radial Artery

Left coronary artery: Fajadet left, Kimny radial, MUTA left, IKARI left,  EBU, Amplatz left (flexible), Judkins left, Multipurpose / El Gamal

· Right coronary artery: Barbeau's, Fajadet Right, Kimny radial,  MUTA right, IKARI right, Multipurpose / El Gamal, Judkins right, Amplatz right, Amplatz left

· Both left and right coronary arteries: Kimny radial, Multipurpose / El Gamal, Amplatz left

· Venous bypass grafts: Kimny radial, Multipurpose / El Gamal, Judkins right, Bypass graft catheters

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