Catheter Selection for Transradial Procedures, Right Heart Catheterization

1. ITS 2011
Catheter Selection for Transradial
Procedures
Right Heart Catheterization
Mauricio G. Cohen, MD, FACC, FSCAI
Mauricio Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Cardiac Catheterization Lab
Associate Professor of Medicine
Associate Professor of Medicine

2. Understanding the Catheter’s Course
Right Radial Left Radial Femoral
2 points of 1 point of 1 point of
resistance resistance resistance

3. TRA: Mechanisms of 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 spasmHydrophylic sheaths not used 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;2:1057-1064

4. Catheter selection – why
Standard femoral Dx catheters may be used as
well as several other universal curves
 Learning curve
 Single vs. Double catheter technique
Judkins: JL3.5 and JR4 or 5
Single catheters:
– Jacky, Tiger, Sarah, Kimny, Fajadet
 TRA PCI
Right: JR4 or 5 – Left: EBU 3.5
Single Catheter Technique: Ikari L

5. ITS 2011
Catheter Selection: Femoral vs Radial
Radial access requires the use of finger-based torque movements instead of
the wrist-based used in femoral access
 Catheter Manipulation
 Catheter Manipulation Technique
Transradial approach can involve more tortuosity than the femoral
Transradial approach can involve more tortuosity than the femoral
approach
approach
TRA necessitating small (finger-based) clockwise and
TRA necessitating small (finger-based) clockwise and
counterclockwise torquing movements and active catheter holding
counterclockwise torquing movements and active catheter holding
as there may be multiple friction points in the subclavian and the
as there may be multiple friction points in the subclavian and the
aorta
aorta
JL 3.5 Radial JL 4.0 Femoral
Different curve mechanics,
sizing and backup support

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

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

8. ITS 2011
Transradial Curves for Left Coronary – Extra Backup
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 Apply torque to point the tip to the left coronary cusp
BSC: Muta Left, Radial Curve, and turn catheter. Pull wire back and the catheter will
Brachial Curve engage the left coronary artery. Backup support from
the sinus of valsalva

9. ITS 2011
Transradial Curves for Left Coronary – EBU
Transradial Curves for Left Coronary – EBU

10. ITS 2011
Single Catheter Solutions
for Diagnostic Catheterization
Terumo’s Optitorque
Diagnostic Catheter
Available in 5F and 6F
Amplatz
shape tip
Tiger Jacky
Rarely coaxial, good for Amplatz type tip (to
RCA, the tip tends to address engagement
point superior issues), better suited for LV

11. Jacky Catheter: Selective Engagement of
RCA and LM

12. IKARI Left Catheter

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

14. IKARI Left Catheter: Multivessel
Intervention

15. 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: Judkins engagement technique, similar to
femoral approach. Apply a clockwise
Cordis: Judkins Right
rotation to engage right coronary artery
BSC: Judkins Right

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

17. ITS 2011
Universal Transradial Curve – MAC3030

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

19. 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

20. 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

22. Diagnostic Catheters for PCI?

23. Conclusions
 Find the catheter that works best for you – Practice
makes perfect
Consider starting with Judkins and transition to single
Consider starting with Judkins and transition to single
technique once confident.
catheter technique once you feel more confident.
 Guiding catheter engagement and support represent
significant barriers to transradial procedural success
catheter cannulate
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
ablation
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.

25. Access Technique

 Place an IV in the holding area and exchange over the wire
IV wire

 Apply tourniquet, inject contrast in the artery and wait for
contrast in the artery and wait for
the venous phase to stick

 Use real-time ultrasound

28. Right Heart Catheterization
via Antecubital Vein

29. Right Heart Catheterization
via Antecubital Vein

30. Right Heart Catheterization
via Antecubital Vein

31. ITS 2011
Universal Transradial Curve –
MAC3030
 for
 Single catheter for diagnostic
interventional
and interventional
procedures
The catheter is pulled back into
The catheter is pulled back into
the aorta to document a
the aorta to document a
pullback gradient across the
pullback gradient across the
aortic value
aortic value
Angled Tip
The RCA ostium is engaged
The RCA ostium is engaged
with gentle clockwise torque as
with gentle clockwise torque as
the catheter is slowly advanced
the catheter is slowly advanced
into the right coronary cusp
into the right coronary cusp
The internal lumen of the MAC3030 facilitates The catheter is removed from
The catheter is removed from
its use in all coronary interventions the RCA ostium by pulling back
the RCA ostium by pulling back
while using counterclockwise
while using counterclockwise
torque and is placed in the left
torque and is placed in the left
main ostium
main ostium

32. Transradial Curves for Right ITS 2011
Coronary - Other
RRAD
Easy Radial Right
Comparable to: Comparable to:
Cordis: Hockey Stick Cordis: RB MP (Saito Technique), BRC
* Available with long and short tip MRESS
Comparable to:
Cordis: Barbeau

33. ITS 2011
Transradial Curves - Multipurpose
Multipurpose* MRADIAL*
Comparable to:
Cordis: RB
BSC:Kimney
Left: MBI/MP2
Right: MPST

34. ITS 2011
Transradial Curves - Multipurpose
ALR12* ALR12*
Comparable to: Comparable to:
Cordis: Castillo Cordis: Castillo
Hockey Stick* Hockey Stick*
Comparable to:
Cordis: Hockey Stick