Basic principles of the procedure Frijo Jose A Slide 2 Slide 3
Slide 4 Comparison- Diagnostic v/s Guiding catheters Stiffer shaft
Larger internal diameter (ID) Shorter & more angulated tip (110
vs. 90) Re-enforced construction (3vs.2 layers) Slide 5 Guide
catheter construction Slide 6 Curves in guide catheter Slide 7
Guiding catheter For each given size of, its ID is either a
standard, large or giant lumen Larger sizes better opacification of
the contrast better guide support allow pressure monitoring
increased risk of ostial trauma, vascular complications and the
possibility of kinking of catheter shaft Slide 8 Slide 9 Slide 10
Judkins and Amplatz Judkins Extremely useful as a diagnostic cath -
1 curve is fixed Intubates small segment of ostium - risk of trauma
Limitation while performing PCI - 1 curve is fixed May not be
co-axial as cath makes an angle of ~90 with cor - may be difficult
to pass balloons-esp LCX JL- point of contact on asc Ao -very high
& narrow- chance of prolapse & dislodgement JR- no point of
contact on asc Ao - extremely poor support Slide 11 Backup force 3
factors Catheter size Area of contact made by cath on Ao Angle
(theta) of cath on the reverse side of Ao The angle (theta)
determines the force that can dislodge the guiding catheter. Slide
12 Slide 13 If this angle is 90, 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 90 Slide 14 Slide 15 Other Guiding Catheters Long tip
cath like Xtra backup (XB) & Extra back up (EBU) modifications
for JL- stiffer & free 1 curve more co-axial & support XB
distal tip - lies more horizontal within cor, sometimes pointing ,
& intubating more LMCA Longer segment of XB cath comes in
contact with contra- lat wall of Ao- back-up support XB cath- ~67%
additional support v/s JR- at the cost of likelihood of trauma
LMCA, esp - pre-existing plaque stiffer - chance of injury XBLAD -
support for LAD interventions specifically Slide 16 Xtra backup
(XB) tip Slide 17 Guide Catheter for RCA Interventions JR or Hockey
Stick (HS) is usually preferred Extra-support-(CTO/tortuous)- AL1
MP cath- esp abn take-off, esp inf Three dimensional right curve (3
DRC) cath- tortuous, bent anatomy & postr/supr take off of RCA
XBR & XBRCA -new caths specifically for inf & sup take off
of RCA respectively Slide 18 Slide 19 Guide Catheter for LCX
Interventions JL 4 may be gently rotated clockwise to achieve a
stable co-axial alignment Ao root dialated / if JL 4 points
anteriorly- JL 5 If additional support AL cath recommended Unlike
JL, a simple withdrawal can cause the tip to advance even furthe-
best way to disengage an AL is to advance it slightlyprolapse tip
out of cor & then rotate it out of the ostium Voda cath- esp
when a double PTCA of LAD & LCX in same sitting Slide 20 The
Voda catheter Slide 21 Side Holes v/s No Side Holes Side holes
where P gets freq damped (RCA) where prolonged intubation of cor
mandated (CTO) to know P through out PCI (sole surviving art /
LMCA) P will not be damped allow additnl blood flow out the tip-
perfuse cor may also avoid catastrophic dissections in the ostium
of the artery if the guide catheter is not co-axial it can be a
false sense of security Ao P, not cor P is being monitored
suboptimal opacification back up support- weak cath shaft &
kinking at side holes Slide 22 Guide Techniques for PCI of Tortuous
Arteries Deep Seating of Guide cath deeply intubated into cor-
support RCA/LCX - clockwise rotation & gentle advancing of
guide over the guide wire LAD - counterclockwise rotation risk of
dissection & embolization, esp degenerated SVG Slide 23 Guide
Techniques for PCI of Tortuous Arteries Child in Mother Technique
110cm long 5Fr guide (Child) in 100cm long 6Fr/7Fr guide catheter
(Mother) May provide up-to 70% more support Trauma to vessel
dissection Air embolism usually occurring during intubation of
child catheter/during CAG performed via mother guide Slide 24
Shepard's Crook RCA Dramatic upturn with a 180 switchback turn
AL1/0.75 & 3DRC are best suited for this anatomy Slide 25 Guide
wire - construction Most - calibre of 0.014 inch Multi-layer
constructions: 1.Core element (usually stainless steel/or nitinol):
tapers at variable points towards wire tip to impart differential
stiffness along wire's length 2.Terminal coil segment (often 30mm
length; usually radio-opaque material e.g. platinum/iridium
alloys): gives flexibility and allows wire tip to be shaped per
operator requirements 3.Coating: most wires silicone/Teflon outer
coating to aid easy advancement. Some coated with a hydrophilic
polymer coating that becomes a gel when wet to reduce surface
friction and increase wire slipperiness Slide 26 Guide wire -
construction Most - calibre of 0.014 inch 3 main components of
guidewire design: central core outer covering exible distal tip The
wire tip may be further subdivided into spring coil & short
distal tip weld Also, all guidewires have a specic surface coating
applied Slide 27 Central core Longest & stiffest portion of
guidewire Tapers distally to a variable extent 2-piece core- distal
part of core does not reach distal tip of wire shaping ribbon,
extends to distal tip 1-piece core- tapered core reaches distal tip
weld 2-piece easy shaping & durable shape memory 1-piece better
force transmission to tip & greater tactile response for
operator Slide 28 Slide 29 Central core Stainless steel superior
torque characteristics, can deliver more push, provides good
shapeability of tip in core-to-tip design wires more susceptible to
kinking Durasteel- better tip shape retention and durability
Nitinol pliable but supportive, less torquability than SS generally
considered kink resistant & have a tendency to return to their
original shape, making them potentially less susceptible to
deformation during prolonged use Slide 30 Distal tip Flexible,
radio-opaque part Consists of spring coil extending from distal
untapered part of central core to distal tip weld Integrates
tapered core barrel (as well as shaping ribbon in 2-piece wire)
Spring coil-variable length (1-25cm)-radio-opaque section located
at its terminal end Distal tip weld- short (2mm)compact cap forming
the true distal end of the wire - to trauma while the wire is
traversing vessels Slide 31 Slide 32 Slide 33 Wire
Coating-hydrophilic/hydrophobic Hydrophobic Repels water - requires
no actuation/wetting friction (to V/S no coating), trackability
Preserves tactile feel, allows easier anchorability / parking - esp
CTO Silicone, Teflon Slide 34 Hydrophilic Attracts water - needs
lubrication Thin, slippery, non-solid when dry becomes a gel when
wet friction( no coating) glide through tortuous trackability
Thrombogenic tactile feel- risk of perforation Tendency to stick to
angioplasty cath Useful in negotiating tortuous lesions and in
finding microchannels in total occlusions Lubricity is highest with
hydrophilic wires, less with Silicone coating and least with PTFE
or Teflon coating Slide 35 Properties Of An Ideal Guidewire Push
transmission/steerability Torque transmission/torquability Body
support/ trackability Tip support/mobility Flexibility Tip
durability/elasticity Tip visibility and markers Tactile feedback
Prolapse tendency Slide 36 Push transmission/steerability: ability
of a guide wire tip to be delivered to the desired position in a
vessel Torque transmission: ability to transmit rotational forces
from the operators hand to the tip Body support/ trackability:
ability to advance balloon catheters/other devices on guidewire Tip
support/mobility: Allows moving the distal tip to search for the
true lumen Tip durability/elasticity: Permits shape memory
retention of the distal tip throughout Tactile feedback: feel of
the wire tips behavior, as perceived by the operator better
appreciated with non-coated / hydrophobic coated, coil tipped wires
and it with hydrophilic coating Slide 37 Slide 38 Shapeability and
shaping memory Shapeability - allows to modify its distal tip
conformation Shaping memory - ability of tip to return back to its
basal conformation after having been exposed to deformation &
stress Both do not necessarily go in parallel SS core wires -easier
to shape (memory- nitinol core) 2-piece core + shaping ribbon -
easier to shape & memory General rule- when negotiating a
vessel with J loop, distal bend ~ D of vesselmore bend - wire tip
prolapsing, less bend - steerability Slide 39 Types Of Guidewires
Depending on tip load- Balanced, Extra support, Floppy Tip load-
force needed to bend a wire when exerted on a straight guide wire
tip, at 1 cm from the tip Balanced 0.5-0.9g Extra support -
>0.9g Floppy -
