South Korea

Japan
My house
TRI and Guiding Catheter
Tip & Tricks in guiding selection

Seong-Man Kim MD
Inje University
Busan, Korea
Historical view

Gruentzig
Judkins Amplatz
Sones

Ikari Tiger
Transradial or Transfemoral ?

Is there any difference?

Femoral is better !!!
2 types of Guiding Catheter esp. in LCA procedure

1. Over-bending ; Judkins, EBU, Ikari

2. Under-bending ; Amplatz
Guiding Catheter Exchange during femoral PCI

one operator, 1986 -1989, 683 pts

Exchange group: 43 pts (6.3%)

Target vessel 1st , n=683 2nd , n=43

LAD JL AL

LCX JL AL

RCA AR, JR AL

Catheterization and Cardiovascular diagnosis 1990:20;212-215

Real Procedure in East Asia (Guiding Catheter)

LCA, RCA
LCA:  
Radial – Judkins 60%
Radial XB 20%
rest 30%: Ikari, Amplatz
25%   Femoral – Judkins 80%
other: XB, Amplatz

Femoral
RCA:
75% Radial - Judkins 60%
Amplatz 25%, other: Ikari,
  Femoral – Judkins 80%, others 20%

Terumo branch survey 2004’

Real Procedure in South Asia (Guiding Catheter)

LCA, RCA
LCA:  
Radial – Judkins 60%
Radial XB 20%
rest 30%: Amplatz
10%   Femoral – Judkins 80%
other: XB, Amplatz

Femoral
RCA:
90% Radial - Judkins 60%
Amplatz 25%, other: Ikari,
  Femoral – Judkins 80%, others 20%

Terumo branch survey 2004’

Commonly used shape of guiding catheter

Transradial Approach
- LCA: JL, XB, AL
- RCA: JR
Transfemoral Approach
- LCA: JL, XB, AL
- RCA: JR

New shape ?
Factors in selecting Guiding Catheter in TRI

Coronary artery ostium

- angle between aorta and ostium

Lesion location & nature

- LM, RCA ostium
- proximal, mid, distal
- Acute MI, CTO
- heavy calcification, acute angle

Back-up power
- material
- alignment
- opposite side of aortic wall
Anatomy LAO view
Anatomy LAO view

Common Anatomy
RCA
RCA – horizontal angle (mc) LAO view
RCA – horizontal angle (mc) – Simple lesion LAO view

or
RCA – horizontal angle (mc) – Simple lesion LAO view

Simple lesion RCA

JR is enough
RCA – horizontal angle (mc) – Complex lesion LAO view

?
RCA – horizontal angle (mc) – Complex lesion LAO view
RCA – horizontal angle (mc) – Complex lesion LAO view
RCA – horizontal angle (mc) – Complex lesion LAO view

Need more back-up ?

AL is better
But RCA ostium?
JR is better
RCA – horizontal angle (mc) LAO view

Grasp all together !!

RCA – horizontal angle (mc) LAO view

?
RCA – horizontal angle (mc) LAO view
RCA – horizontal angle (mc) LAO view
RCA – horizontal angle (mc) LAO view
RCA – horizontal angle (mc) LAO view
RCA – horizontal angle (mc) LAO view

Pls. Consider
the distance
between AV
and RCA ostium
RCA – upward angle LAO view

AL
Hockey-stick
El Gamal
Internal Mammary
Voda-right
RCA – upward angle LAO view

AL
Hockey-stick
El Gamal
Internal Mammary
Voda-right
RCA – downward angle LAO view
RCA - Summary

Simple lesion – Anything

More back-up: AL
Short distance: JL
Ostium: JL
Up or down angle: specific catheter
Is there
an ideal guiding catheter
Which can be used
in every cases?
How about this one?
LCA
LCA – horizontal, anterior (mc)

?
LCA – superior

Simple lesion
in LAD, LCX

JL is enough
LCA – superior

Amplatz….better !!
LCA – JL …weak back-up support
LCA – JL
LCA – superior

Be careful…

Tip of JL !!!
LCA – left main lesion JL
LCA – left main lesion JL
LCA – left main lesion JL
LCA – left main lesion TIGER

6 month Follow-up
LCA – superior

Severe LM lesion…
Consider femoral…
Because
Hemodynamic
support !!!
Otherwise Radial..OK
LCA – short or no LM
LCA – short or no LM (LAD lesion) AL
LCA – short or no LM (LCX lesion) AL
LCA – short or no LM (LCX lesion) XB
LCA – short or no LM (LCX lesion)

Short or no LM
AL is better…
Reason:
1. Usually select one artery (LAD or LCX)
2. Restore its original shape often
3. Unstable selection
LCA – short or no LM (LCX lesion) AL
LCA - Summary

1. Pls. Be careful – tip of JL

2. Simple lesion in LAD, LCX
– JL is enough
3. LM lesion
– consider Patient’s condition
lesion’s characteristics
4. Short of no LM – consider AL
REC. Guiding for LCA in TRI

JL 4.0 XB 3.5 IL 4.0

JL 3.5 XB 3.0 IL 3.5
REC. Guiding for RCA in TRI

JR 4.0 AL 0.75
TR
JR 5.0 AL 1,2
Ideal Guiding Catheter for LCA

Case
 Case
Ideal Guiding Catheter for LCA

JL guiding AL guiding
 Case
Ideal Guiding Catheter for LCA

AL guiding with Ballooning

Ideal Guiding Catheter for LCA

Tried femoral approach with JL and AL also

But fail to put a stent
 Case
Ideal Guiding Catheter for LCA

Stenting….Ideal Guiding Catheter !!

 Case
Ideal Guiding Catheter for LCA

Before After
Ideal Guiding Catheter for LCA

?
Kissing
Balloon
or
Stent
 Guiding Catheter comparison chart 　　　　　　　　　　　
　　　

Name Company I.D. O.D.

Heartrail Terumo 0.071 1.80mm 2.06mm
ZUMAⅡ Medtronic 0.070 1.79mm 2.08mm
Launcher Medtronic 0.071 1.80mm 2.06mm
Mach1 Boston 0.071 1.79mm 2.08mm
Vikig Guidant 0.066 1.72mm 2.09mm
Viking-Optima Guidant 0.068 1.78mm 2.06mm
Britetip J&J 0.067 1.72mm 2.04mm
Britetip 0.071" J&J 0.070 1.77mm 2.06mm
 Guiding Catheter comparison chart 　　　　　　　　　　　
　　　

6Fr.I.D.=0.071”
5F 6F 7F 8F 9F 10F
TERUMO Heartrail 0.059" 0.071" 0.081" 0.091"
Cordis BriteTip 0.057" 0.070" 0.078" 0.087" 0.098" 0.110"
Medtronic Zuma2 0.058" 0.070" 0.081" 0.091"
Medtronic Launcher 0.071" 0.082"
Boston Mach1 0.071" 0.081" 0.091"
Guiding Catheter 　 6Fr 　　　　　　　　　　　　　

2.06-2.08 mm
1.8 mm
 Coronary Balloon Comparison Chart

Abbott

Manufacturers Cordis Guidant Boston Terumo Medtronic

Vascular

Specification Aqua T3 Crossail Maverick 2 Ryujin Splinter Stormer Jo Maestro

Entry Profile 0.43 0.48 0.43 0.43 0.4 0.495 0.43

Compliance Dual Semi Semi Semi N/A Semi Semi

Crossing Profile 0.81 0.84 0.81 0.79 N/A 0.94 N/A

Distal Shaft Size 2.7Fr. 2.4Fr. 2.4Fr. 2.7Fr. N/A 2.5Fr. 2.7Fr.

mm
 Coronary Stent Comparison Chart

Company Medtronic Guidant Terumo Cordis Boston Jomed

Product Driver Vision Tsunami Cypher Taxus Jostent

Strut Thickness 0.09 0.081 0.08 0.139 0.127 0.09

Crossing Profile 1.17 N/A 0.95 1.13 1.12 N/A

Proximal Shaft Profile 2.7Fr. 2.7Fr. 2.7Fr. 2.7Fr. 2.7Fr. 2.7Fr.

Mounted Balloon Splinter Crossail Arashi Raptor(N/A) Maveric Maestro(N/A)

mm