Essentials of Catheter Selection: Optimizing Engagement and Support

Essentials of Catheter Selection: Optimizing Engagement and Support Carlos E. Alfonso, MD Cardiology Fellowship Program Director Associate Professor of Medicine 1

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 Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company None Merritt Medical None None None None None

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 spasm 34% Radial artery dissection 10% Hydrophylic sheaths not used 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 3

Understanding the Catheter s Course Right Radial Left Radial Femoral 2 points of resistance 1 point of resistance 1 point of resistance 4

Effect of Inspiration α α A B Panel A: During expiration there is a more acute angle (α) between the brachiocephalic trunk and the ascending aorta, therefore the wire takes a more horizontal a more horizontal direction towards the descending aorta. Panel B: During deep inspiration, the diaphragm lowers the heart and straightens the angle (α) between the brachiocephalic trunk and the ascending aorta. The wire takes a more vertical direction towards the ascending aorta. 6

Radial Side Selection The back-up force provided by the guide catheter differs according to the radial side Courtesy Francesco Burzotta 7

Cases TALENT TRIAL: Right vs. Left Radial Cross-over to Femoral: Incidence and Classification 5 4 3 P= 0.41 P= 0.70 RRA (n= 770) LRA (n= 770) 2 Overall 14 puncture and radial failure vs 1 epi-aortic failure, p= 0.0008 1 P= 0.31 P= 0.31 0 Lack of radial canalization Radial tortuosity/anomalies Severe spasm Subclavian-aortic tortuosity Puncture Failure Radial Failure Epi-Aortic Failure Sciahbasi A et al. Am Heart J 2011;161:172-9. 8

TALENT TRIAL: Right vs. Left Radial Operator s experience matters Sciahbasi A et al. Am Heart J 2011;161:172-9. 9

Catheter selection Learning curve Single vs. Double catheter technique Judkins: JL3.5 and JR4 or 5 Single catheters: Tiger, ULT1, Jacky, ULT2, Sarah, ULT3, Kimny, Fajadet TRA PCI Right: JR4 or 5 Left: EBU 3.5 Single Catheter Technique: Ikari L 10

Diagnostic Radial Catheters Merit Ultimate 1 Merit Ultimate 2 Merit Ultimate 3 Merit Ultimate 4 These are radial catheters used to cannulate the right and left coronary arteries with just one shape.

Ultimate 1 and 4 The Ultimate 1 and 4 are come from the Judkins Left catheter This is why they are the most popular of the Ultimate catheters. Ultimate 1 and Ultimate 4 are just a relaxed version of a Judkins Catheter

Ultimate 1 why it s better than the Tiger The Tiger has a pinch point that makes it vulnerable to fold back on itself. The tertiary curve allows for added support.

Ultimate 2 and Ultimate 3 from Amplatz 3.5cm 4.0cm Ultimate 2 (3.5cm) Terumo Jacky Good for dilated roots where you need extra reach Ultimate 3 (4.0cm) Terumo Sarah Ultimate 2 and 3 are more like Amplatz catheters that get support at the bottom of the aortic root and give you more reach

Ultimate 3 The Ultimate 3 is an Ultimate 2 layed out a little further. This catheter is for dilated aortas or extreme takeoffs. Ultimate 3

Most frequently used diagnostic coronary catheter shapes ULT1 ULT4 Tiger Jacky Amplatz Left LCB RCB Judkins Left Judins Right Multipurpose A2 IM 3D LIMA IM VB-1 17

Catheter selection - Radial vs. Femoral Radial Hinge Femoral Femoral Radial Ikari Y, et. al. Journal of Invasive Cardiology 200 18

Catheter Selection: Femoral vs Radial Catheter Manipulation Technique Transradial approach can involve more tortuosity than the femoral approach TRA necessitating small (finger-based) clockwise and counterclockwise torquing movements and active catheter holding as there may be multiple friction points in the subclavian and the aorta JL 3.5 Radial Different curve mechanics, sizing and backup support JL 4.0 Femoral 19

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: Merit: SBS ConcierGE 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

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: Merit: Judkins Right Cordis: Judkins Right BSC: Judkins Right Judkins engagement technique, similar to femoral approach. Apply a clockwise rotation to engage right coronary artery 22

Transradial Curves for Right Coronary Judkins Right Deep intubation of RCA with JR4 23

Comparison of Backup Force in TRI A B C D JR IR AL IL max resistance (g force) 160 140 120 100 80 60 40 20 0 JR4 IR1.5 AL1 IL3.5 24

AMPLATZ for Complex PCI 25

AMPLATZ for Complex PCI 26

Guideliner Case / Mother-Child Case 27

Guideliner Case 28

Guideliner Case 29

Guideliner Case 30

Be Careful With Aggressive Guides 31

Plourde G et al. AIM RADIAL 2013 33

Plourde G et al. AIM RADIAL 2013 34

Dedicated Radial Catheters Performa Ultimate Merit Ultimate 1 Merit Ultimate 2 Merit Ultimate 3 Merit Ultimate 4 These are radial catheters used to cannulate the right and left coronary arteries with just one shape. 36

Jacky Catheter: Selective Engagement of RCA and LM 37

Using JL 3.5 as Universal Catheter 38

Using JL 3.5 as Universal Catheter 39

TRA in Patients with Grafts Pattern of coronary grafting LIMA LIMA + RIMA LIMA + RIMA + RA LIMA + SVG(s) SVG(s) Suggested primary approach Left Radial Right Radial or Femoral Femoral Left Radial Right Radial or Left Radial Comments Documented facilitation compared to femoral approach Avoid contralateral cannulation in severe atherosclerosis of the aortic arch and subclavian arteries Consider aortography to visualize SVGs and facilitate catheter selection Left radial easier, specially during the learning curve Burzotta F et al. CCI 2008;72:263-272 40

Patients with coronary bypass grafts: Tips and tricks Judkins Right or Multipurpose Amplatz Left, ULT1 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 41

Challenges: Double Mammary Case 43

Challenges: Double Mammary Case VB-1 48

Right IMA Angiography Panel A: the IM catheter cannot selectively engage the right IMA because of its sharp origin angle providing suboptimal images. Catheter Tip Panel B: a more angulated catheter, such as the IM- VB1, can selectively cannulate the right IMA without difficulty providing optimal angiographic opacification of the vessel. A B 49

% of Patients 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 8 n=171 6 5.9 Radial Artery Occlussion 4 2 1.1 0 5 Fr 6 Fr Proc Success 95.4% 92.9% Dahm J et al. CCI 2002; 57:172 176 50

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 51

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 52

Conclusions Find the catheter that works best for you Practice makes perfect Consider starting with Judkins and transition to single catheter technique once you feel more confident. 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 atherectomy TR specific guiding catheters may offer advantages Dedicated sheathless guiding catheters now available in the US, but sheathless is possible with standard equipment. 56

THANK YOU!! Mauricio Cohen Cell: 305-873-4513 mgcohen@med.miami.edu Carlos E Alfonso Cell: 305-606-1988 calfonso@med.miami.edu CALL US (or any of the faculty)!!! Share images, complications, advice 57