30.

2
Sheaths

Emmanouil S. Brilakis, MD, PhD

 PCI: the steps
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 Sheath characteristics

1. Diameter
2. Length
3. Thickness
4. Kink resistance
1. Diameter
 Outer diameter
French
Gauge (mm) (inches)
4 1.333 0.053
5 1.667 0.066
6 2 0.079
1 French = 7 2.333 0.092
0.33 mm 8 2.667 0.105
9 3 0.118
10 3.333 0.131
11 3.667 0.144
12 4 0.158
13 4.333 0.170
14 4.667 0.184
 Sheath ext: 2.62 mm

Sheath int: 2.06 mm

6 French guide in
6 French sheath

Catheter ext: 2.0 mm

Catheter int: 1.8 mm
 Sheath ext: 2.62 mm

Sheath int: 2.06 mm

6 French diagnostic
catheter in
6 French sheath

Catheter ext: 2.0 mm

Catheter int: 1.3 mm
 Catheter selection

• Diagnostic vs. guide

Guide - HeartRail
• Shape
• Size (French) Diagnostic - Optitorque
• Length
• Side holes
• Surface
How big guide do you need?

Iannacone M et al. Eur Heart J 2020;41:342-344

 Large bore devices

Sheath diameter needed:

• IABP: 7-9 Fr
• Impella: 13 Fr
• Impella CP: 14 Fr
• VA-ECMO: 15-17 Fr
 Risk of lower extremity ischemia

4F 5F
Femoral artery lumen diameter: 6mm

Proportion of the cross sectional

lumen area occupied by the sheath
0% 10.7% 11.1%

6F
7F 8F

Proportion of the cross sectional

lumen area occupied by the sheath 14.5% 24.2% 30.6%

9F 10F
11F

Proportion of the cross sectional

lumen area occupied by the sheath 38.6% 53.5% 64.8%
2. Length
 Sheath characteristics

1. Diameter
• Diagnostic: 4-6 Fr
• Guide: 5-8 Fr
2. Length
• No tortuosity: 10 cm
• Tortuosity: 25-45 cm
3. Thickness
Prelude IDeal™ Hydrophilic Sheath, Merit Medical
• Radial: thin walled OD: 2.46 mm

4. Kink resistance
Sheath length
A B 25 cm
long
sheath
12 cm long
sheath
25 cm long sheath for left radial

Courtesy: Dr. Stephane Rinfret

3. Thickness
 Thin walled radial sheaths

1. Easy to use
2. 5-7 French – no 8 French available
3. Kinking

Terumo slender
Merit Prelude Ideal
 Outer sheath diameter: ≈ same as the outer
diameter of a guide catheter two sizes bigger

5 French, 125 cm long, Cook Select catheter to insert 7 Fr guide 

Courtesy: Dr. Jaikirshan Khatri
 Cordis Railway
Sheathless guides

• Pros: Cross braided and hydrophilic, great I.D. for complex PCI
• Cons: No tip marker, stiff tip, limited shapes

7.5F Asahi Eaucath

6/13/23 21
4. Kink resistance
Super Arrow Flex: for antegrade limb perfusion
in VA-ECMO
 Sheath characteristics
1. Diameter
• Diagnostic: 4-6 Fr
• Guide: 5-8 Fr
• Hemodynamic support: 8-25 Fr
2. Length
• No tortuosity: 10 cm
• Tortuosity: 25-45 cm
3. Thickness
• Radial: thin walled
4. Kink resistance