Guide Catheters & Guidewire :

overview and case illustrations

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
 Objectives
• 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
 Diagnostic vs Guide Catheter
Diagnostic Catheter Guiding Catheter

Engage Coronary Conduit for device &

Arteries Wire

Pressure Assessment Support of equipment

Coronary Angiography Injection of Contrast

Pressure
measurements

Angiographic
Assessment

Source: Grossman’s Cardiac Catheterization, Angiography, and Intervention

 Guide catheters
Compatibility with devices and techniques
Catheter Size Devices Techniques
Balloons < 5 mm
Stents < 4.5 mm
5 Fr IVUS No Kissing Balloon
Rotablator 1.25 mm

All Coronary balloons

All Coronary stents
Cutting Balloon
6 Fr Rotablator < 1.5 mm
CSI orbital atherectomy 1.25 mm Kissing Balloon
Protection device
Guideliner

JoStent*
7 Fr Rotablator 1.75 mm
Guideliner
Simultaneous Kissing Stent
Trapping balloons

Rotablator 2 mm
8 Fr Guideliner
Trapping balloons
Trifurcation stenting
Guide Catheters
Guide catheter selection : Key considerations
• Radial vs. femoral approach
• Anticipated degree of support vs. needed I.D. vs. both
• Aortic anatomic considerations
• Diameter of ascending aorta (small, NL, dilated)
• Tortuosity of aorta & iliofemoral system impacting catheter length and
handling
• Target vessel considerations
• Size of TV ostium and presence of disease
• Target segment for PCI (ostial vs. proximal-­‐distal?)
• Takeoff location (NL/ant/post) vs SOV
• Takeoff angle (NL vs. high/low)
• Strategy for engagement & support
• Coaxial vs. non-­‐coaxial positioning vs. deep intubation
• Support from ipsilateral SOV vs. backup
• Specific interactions between device and guide curve (esp.
atherectomy)
 Backup Support

Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization,

Angiography, and Intervention
 Curve / Tip Length

5.0

3.0 4.0

4.0 4.0 3.0

5.0

Tip Orientation Lateral Wall Support

Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization,
Angiography, and Intervention
 Coaxial Alignment

Coaxial Non-Coaxial

Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization,

Angiography, and Intervention
Common guide shapes for extra support from the
Sinus of Valsalva

Amplatz le ft

Hockey
Amplatz right Multi purpose
sti ck Coaxial alignment,
with support from
the ipsilateral Sinus
of Valsalva
 Curve Length
P S
AL

P
S
P = Primary Curve
S = Secondary Curve
S

P AR
JR4
Common guide shapes for power support from
contralateral aortic wall

Extra support (XB)

Extra backup (EBU)

Coaxial alignment,
with power support
from the opposite
wall of the aorta
Catheter Choice based on Anatomy
 Vessel Takeoff

Inferior
Posterior

Superior

Anterior

Acute

Source: The Manual of Interventional Cardiology

EBU Family of Catheter
Catheter Engagement
Catheter course: Radial vs. femoral

Femoral Right Radial Left

Radial

1 point of 2 points of 1 point of

resistance resistance resistance
 Universal radial guide catheters
Catheter manipulation from right radial approach

Curve A to fit angle of brachiocephalic

artery.

Straight portion (20 mm) B to generate

strong back-­‐up force supported by opposite
side of aortic wall.
Universal vs. Judkins
catheters?
Advantages Advantages
• Single pass through radial artery = • Cost
potentially less time and less spasm • Familiarity / availability

Disadvantages Disadvantages
• Cost • More time
• Learning curve • More passes through radial artery
• Potentially more catheter potentially = more spasm
manipulation
Ultimate 1 Ultimate 2 Performa JL4 JR4 pigtail MIV pigtail
Ultimate 3
Catheter selection: Key considerations

The Basics
• Standard size – JL4.0 for access from left arm
• Size down ½ size for access from the right arm (+/-­‐ left arm)
• Finger torque technique
–Small torqueing movements (clockwise and
counterclockwise).
–Fingertip 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
Catheter selection: Key considerations

• High probability of FFR, IVUS/OCT, PCI: Consider starting 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 / distortion
(advanced age, PAD, aortic dilatation/aneurysm, thoracic
anomalies such as scoliosis, pneumonectomy, etc.) usually
favors L radial approach with appropriate catheter selections
• Large pannus, inability to bring in / slightly pronate L arm
usually favors R radial approach with appropriate catheter
selections ‘
 Other catheters worth knowing

Cobra C1 Cobra C2 Non-­‐torque IMA RIM

VB-­‐1 right
Engaging bypass grafts from
the wrist
Basic Coronary Guide Wire Characteristics

Steerable
“Deliverable”

Atraumatic Adequate Smooth

Tip Rail Support Coating
 Guidewire Construction

3 basic components

Central Core Tip : Lubricious

Stainless steel Polymer sleeve Coating
Durasteel™
nitinol/Elastinite® or Silicone
PTFE
Coil-­‐Spring Tip
Platinum
Coronary Guidewire
Core Diameter

Smaller Diameter = More Flexibility

Larger Diameter = More Support & Torque

 Core Taper

Longer taper-­‐ superb wire tracking, less prolapse

Shorter taper-­‐ longer segments of consistent support, more prolapse

30
 Core Taper
• Abrupt or short tapers produce a core which provides
greater segment length of support but also greater
tendency to prolapse

Prolapse

31
 Core Taper
• Broad, gradual or long tapers produce a core which
offers greater tracking and wire which prolapses
less

Successful
Tracking

32
Core Material
 Core Material
• Stainless steel
– Original core material technology
– Good support, push force and torque
– Less flexible than newer core materials

34
 Core Material
• Nitinol/Elastinite®
– Super-­‐elastic alloy designed for
kink resistance
– Excellent flexibility and steering
– Durable nature may facilitate treatment of
multiple lesions and/or tortuous vessels
– No memory
Work-­‐Horse Guide Wire Characteristics

• Intermediate Core Diameter

• Gentle Core Taper
• Resilient Core with good torque control
• Soft Tip
• Coils or Covers
• Smooth Coating
Change Coronary Guide Wire Characteristics

Steerable
“Deliverable”

Atraumatic
Stiff IAndcerqe Smooth
Hydrophilic
Spring
Tip Tip ausaeted Coating
Coating
Rail Support
Dissections & Straightening Perforation
Perforations Artifacts
Pseudolesion

Saf a e l
 Guide Wire ‐-­ Coating

POLYMER AND
LUBRICITY

HYDROPHILLIC

HYDROPHILLIC

HYDROPHOBIC

NO COATING

TACTILE FEEDBACK
 Wire Selection
Workhorse Wires Extra Support CTO Wires

• BMW • ACS Intermediate • Stiff

• BMW Universal • Choice ES – Miracle
• Runthrough • Stabilizer – Confianza
• • – Persuader
Hi-­‐Torque Floppy Wiggle Wire
• Prowater
• Slippery
– Fielder FC,XT
– Pilot 50-­‐200
 Special Guide Wire Problems
Problem Solution Compromise

Total Occlusion 0.009” wire Less rail support

- Tapered and/or with 0.009”
hydrophilic wire, wire
coating perforation

-Blunt Stiff Tip Increased

Dissection and
Perforation
 Device Delivery Problems

Problem Solution Compromise

Unable to Stiffer wire or Cost;

deliver a buddy wire or straightening
balloon or flexible stent or artifacts;
stent around better guide or increased risk
a corner Guideliner
 Take-­‐home
points
• Success vs. failure in complex PCI is often heavily dependent on
initial guide catheter selection.

• Three broad guide support styles are:

• Standard (minimal support)
• Ipsilateral SOV
• Power-­‐position (aortic backwall support)

• PCI planning should include technical approach, anticipated

equipment choices, anatomic considerations including presence
of proximal target vessel disease and degree of support
required.
 Take-­‐home
points
• These considerations, in turn, should guide selection of guide
catheter curve/caliber as well as method of guide
manipulation, deep intubation, 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 stiffer sheathless guide
catheter systems.
Thank You