Guide Catheters & Guidewire : overview and case illustra5ons

Transcription

1 Guide Catheters & Guidewire : overview and case illustra5ons Sameer Gupta, MD Interventional Cardiologist & Endovascular Interventionalist Metro Group of Hospitals Noida, UP Diplomate American Board of Internal Medicine Medicine Diplomate American Board of Internal Medicine Cardiovascular Disease Diplomate American Board of Internal Medicine Interventional Cardiology Diplomate National Board of Echocardiography-- (USA) Diplomate American Board of Vascular Medicine Endovascular Intervention

2 Objec5ves Key differences between diagnostic and guide catheters Review the construction, design, & function of guide catheters Identify factors that influence guide catheter selection Discuss guide catheter selection strategies for key clinical challenges

3 Diagnos5c vs Guide Catheter Diagnos5c Catheter Guiding Catheter Engage Coronary Arteries Pressure Assessment Conduit for device & Wire Support of equipment Coronary Angiography InjecBon of Contrast Pressure measurements Angiographic Assessment Source: Grossman s Cardiac Catheterization, Angiography, and Intervention

4 Guide catheters Compa5bility with devices and techniques Catheter Size Devices Techniques 5 Fr 6 Fr 7 Fr 8 Fr Balloons < 5 mm Stents < 4.5 mm IVUS Rotablator 1.25 mm All Coronary balloons All Coronary stents CuOng Balloon Rotablator < 1.5 mm CSI orbital atherectomy 1.25 mm Protec5on device Guideliner JoStent* Rotablator 1.75 mm Guideliner Trapping balloons Rotablator 2 mm Guideliner Trapping balloons No Kissing Balloon Kissing Balloon Simultaneous Kissing Stent TrifurcaBon stenbng

5 Guide Catheters

6 Guide catheter selec5on : Key considera5ons Radial vs. femoral approach An5cipated degree of support vs. needed I.D. vs. both Aor5c anatomic considera5ons Diameter of ascending aorta (small, NL, dilated) Tortuosity of aorta & iliofemoral system impac5ng catheter length and handling Target vessel considera5ons Size of TV os5um and presence of disease Target segment for PCI (os5al vs. proximal- distal?) Takeoff loca5on (NL/ant/post) vs SOV Takeoff angle (NL vs. high/low) Strategy for engagement & support Coaxial vs. non- coaxial posi5oning vs. deep intuba5on Support from ipsilateral SOV vs. backup Specific interac5ons between device and guide curve (esp. atherectomy)

7 Backup Support Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman s Cardiac Catheterization, Angiography, and Intervention

8 Curve / Tip Length Tip Orientation Lateral Wall Support Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman s Cardiac Catheterization, Angiography, and Intervention

9 Coaxial Alignment Coaxial Non-Coaxial Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman s Cardiac Catheterization, Angiography, and Intervention

10 Common guide shapes for extra support from the Sinus of Valsalva Amplatz led Amplatz right Hockey s5ck Mul5purpose Coaxial alignment, with support from the ipsilateral Sinus of Valsalva

11 Curve Length P AL S S P = Primary Curve S = Secondary Curve S P JR4 P AR

12 Common guide shapes for power support from contralateral aor5c wall E x t r a s u p p o r t ( X B ) E x t r a b a c k u p ( E B U ) Coaxial alignment, with power support from the opposite wall of the aorta

13 Catheter Choice based on Anatomy

14 Vessel Takeoff Inferior Posterior Superior Anterior Acute Source: The Manual of Interventional Cardiology

15 EBU Family of Catheter

16 Catheter Engagement

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

18 Universal radial guide catheters Catheter manipula5on from right radial approach Curve A to fit angle of brachiocephalic artery. Straight por5on (20 mm) B to generate strong back- up force supported by opposite side of aor5c wall.

19 Universal vs. Judkins catheters? Advantages Single pass through radial artery = potenbally less Bme and less spasm Advantages Cost Familiarity / availability Disadvantages Cost Learning curve PotenBally more catheter manipulabon Disadvantages More Bme More passes through radial artery potenbally = more spasm UlBmate 1 UlBmate 2 UlBmate 3 Performa JL4 JR4 pigtail MIV pigtail

20 Catheter selec5on: Key considera5ons The Basics Standard size JL4.0 for access from ley arm Size down ½ size for access from the right arm (+/- ley arm) Finger torque technique Small torqueing movements (clockwise and counterclockwise). FingerBp technique is recommended (as opposed to the wrist technique) Standard guide catheter shapes work very well in the radial approach JL4.0, JL3.5, JR4, JR5, EBU3.5, MAC

21 Catheter selec5on: Key considera5ons High probability of FFR, IVUS/OCT, PCI: Consider starbng with a universal guiding catheter In the event of a small radial artery / spasm, it s best to use 4-5 Fr and minimize number of passes through the arm High probability of subclavian tortuosity / distorbon (advanced age, PAD, aorbc dilatabon/aneurysm, thoracic anomalies such as scoliosis, pneumonectomy, etc.) usually favors L radial approach with appropriate catheter selecbons Large pannus, inability to bring in / slightly pronate L arm usually favors R radial approach with appropriate catheter selecbons

22 Other catheters worth knowing Cobra C1 Cobra C2 Non- torque right IMA RIM VB- 1

23 Engaging bypass grafts from the wrist

24 Basic Coronary Guide Wire CharacterisBcs Steerable Deliverable Atraumatic Tip Adequate Rail Support Smooth Coating

25 Guidewire Construc5on 3 basic components Central Core Stainless steel Durasteel nibnol/elasbnite Tip : Polymer sleeve or Coil- Spring Tip PlaBnum Tungsten Stainless Steel Lubricious CoaBng Silicone PTFE Hydrophilic

26 Coronary Guidewire

27

28

29 Core Diameter Diameter affects flexibility, support and torque Smaller Diameter = More Flexibility Larger Diameter = More Support & Torque

30 Core Taper Longer taper- superb wire tracking, less prolapse Shorter taper- longer segments of consistent support, more prolapse 30

31 Core Taper Abrupt or short tapers produce a core which provides greater segment length of support but also greater tendency to prolapse Prolapse 31

32 Core Taper Broad, gradual or long tapers produce a core which offers greater tracking and wire which prolapses less Successful Tracking 32

33 Core Material Affects flexibility, support, steering and tracking Stainless Steel NiBnol/ElasBnite High Tensile Strength Stainless Steel/Durasteel

34 Core Material Stainless steel Original core material technology Good support, push force and torque Less flexible than newer core materials 34

35 Core Material NiBnol/ElasBnite Super- elasbc alloy designed for kink resistance Excellent flexibility and steering Durable nature may facilitate treatment of mulbple lesions and/or tortuous vessels No memory

36 Work- Horse Guide Wire Characteris5cs Intermediate Core Diameter Gentle Core Taper Resilient Core with good torque control SoY Tip Coils or Covers Smooth CoaBng

37 Change Coronary Guide Wire CharacterisBcs Steerable Deliverable Atraumatic Stiff Spring Tip Tip Increased Adequate Rail Support Hydrophilic Smooth Coating Dissections & Perforations Straightening Artifacts Perforation

38 Pseudolesion Safian et al

39 Guide Wire - Coa5ng LUBRICITY HYDROPHOBIC HYDROPHILLIC POLYMER AND HYDROPHILLIC NO COATING TACTILE FEEDBACK

40 Wire Selec5on Workhorse Wires Extra Support CTO Wires BMW BMW Universal Runthrough Hi- Torque Floppy Prowater ACS Intermediate Choice ES Stabilizer Wiggle Wire SBff Miracle Confianza Persuader Slippery Fielder FC,XT Pilot

41 Special Guide Wire Problems Problem Solution Compromise Total Occlusion - Tapered wire and/or hydrophilic coating Less rail support with wire, wire perforation -Blunt Stiff Tip Increased Dissection and Perforation

42 Device Delivery Problems Problem Solution Compromise Unable to deliver a balloon or stent around a corner Stiffer wire or buddy wire or flexible stent or better guide or Guideliner Cost; straightening artifacts; increased risk

43 Take- home points Success vs. failure in complex PCI is oyen heavily dependent on inibal guide catheter selecbon. Three broad guide support styles are: Standard (minimal support) Ipsilateral SOV Power- posibon (aorbc backwall support) PCI planning should include technical approach, anbcipated equipment choices, anatomic considerabons including presence of proximal target vessel disease and degree of support required.

44 Take- home points These considerabons, in turn, should guide selecbon of guide catheter curve/caliber as well as method of guide manipulabon, deep intubabon, etc. The strategy for guide catheter engagement and support should be deliberately formulated pre- PCI (rather than approached in an ad- hoc fashion). When performing complex PCI from TR approach, consider power guides, L>R radial approach or sbffer sheathless guide catheter systems.

45 Thank You