Guide Catheter Selection for Coronary Interventions Flashcards
What is one of the most common coronary anomalies?
Separate ostia of the left coronary artery or a very short left main artery
Occurs in approximately 1% of patients and must be recognized by the operator.
What is often better than obtaining inadequate angiograms of both vessels?
Selectively cannulating and obtaining separate angiograms of the LCx and LAD
What catheter was used to selectively enter the LCx in this case?
JL 4 catheter
What is the most likely maneuver to selectively cannulate the LAD?
Change to the next smaller Judkins curve size, in this case, JL 3.5
What other maneuvers may allow cannulation of the LAD?
- Withdraw the JL 4 slightly and apply clockwise rotation
- Use a smaller backup guide like XB 3.0 or EBU 3.5
What does CT coronary angiography help define?
The course of anomalous coronary arteries in difficult cases
What is a common technical limitation when treating a distal stenosis?
The shaft length of the balloon or stent catheter (typically 135 cm)
How can additional working length be preserved when using a guide?
By using a 90-cm guide instead of a longer one
What is ideal for cannulating vein grafts to the RCA?
An MP catheter
What is important for radial artery interventions?
Adequate guide catheter support
What are the risks associated with larger lumen catheters?
- Increased potential for complications at the puncture site
- Higher contrast loads
- More trauma to the aorta
What should be anticipated for guide catheter selection in CTO cases?
The need for adequate visualization and support
What is an essential component in planning a rotational atherectomy case?
Knowledge of the maximum burr size
What two transcatheter aortic valve bioprostheses are available in the US?
- Edwards Sapien 3 valve
- Medtronic CoreValve Evolut
What is the design of the Sapien 3 valve in relation to coronary ostia?
Designed to be positioned below the coronary ostia
What adjustment is often needed when using Judkins catheters for a right radial approach?
JL catheters should be downsized by 0.5 cm
What could help engage the left main ostium when the catheter tip is just inferior to it?
Gentle clockwise rotation of the catheter
What could be used to reconnect a shortened guide catheter?
A piece of sheath 1 Fr size smaller
What is a common issue encountered with the Judkins catheter in patients of short stature?
The curve size of the Judkins catheter is too large
This can lead to difficulties engaging the left main coronary artery.
What maneuver can help engage the left main coronary artery?
Gentle clockwise rotation of the catheter while the patient takes a deep breath
This helps to pull the ostium downward as the diaphragm moves.
Which catheters are considered ‘longer’ than the JL 4 and may not fit?
- JL 5
- AL 2
- Voda 4
These catheters are typically not expected to fit due to their size.
Where do saphenous vein bypasses to the left coronary typically arise from?
The left anterior surface of the aorta, superior to the native vessels
They usually arise superior to a bypass graft to the RCA.
Which catheters often engage left-sided bypass grafts but do not provide robust backup support?
- JR 4
- LCB
HS and AL catheters provide additional support compared to these.
What is the best catheter choice for a type III aortic arch?
A Simmons catheter
It requires reformation and manipulation to engage the innominate artery.
What is essential equipment requirement when performing rotational atherectomy?
The guide catheter must be large enough to accommodate the atherectomy burr
Good flow is also important for debris washout.
What is a common challenge when using radial arteries for PCI?
Radial arteries can be quite small, potentially not allowing standard 6 Fr sheaths
Operators often report success with 5 Fr guiding systems.
What might pressure dampening indicate during angiography?
Possible significant left main disease
It should be investigated to ensure no obstructive disease is present.
What can diagnostic or guide catheters induce?
Ostial coronary artery dissections
This can occur even with mild, insignificant disease.
Which catheter shapes provide substantial backup for the delivery of stents?
- Amplatz catheter shape
- XB family of curves
- EBU family of curves
- Voda curves
The JL 4 shape provides minimal backup.
What is a challenge when cannulating an anomalous RCA?
It is often very challenging to cannulate due to its atypical origin
Standard left catheters may sometimes be utilized.
What should be done if a guide catheter becomes kinked?
Rotate the catheter in the opposite direction to ‘unkink’ it
A stiff wire may be used to assist in catheter removal.
When should the waveform from the guide catheter be monitored?
Frequently, especially during maneuvers that could change the guide position
This includes when seating the guide, before injections, and during equipment passage.
What catheter should be used for enhanced support with a left-sided SVG?
An AL guide (AL 1, AL 1.5, or AL 2)
Alternatively, LCB or HS catheters may provide additional support.
What catheter is best for an RCA with an upward takeoff?
The AL 1 catheter
Optimal coaxial alignment and backup support are desirable.
Which guide is well suited to cannulate both the left and right coronary arteries?
The Ikari left guide
It facilitates rapid angiography prior to PCI in STEMI settings.
What is the primary purpose of the Ikari left guide?
To cannulate and image both the left and right coronary arteries
This facilitates rapid angiography prior to PCI in the setting of STEMI.
Why might the AL 2 guide be unsuitable for cannulating the RCA?
It is likely too long to cannulate the RCA well
Although it is still possible to use it.
Which guide is not able to cannulate the left main?
The JR 4 guide
This guide is ineffective for this purpose.
What is a limitation of the JL 3.5 guide?
It would not easily cannulate the RCA
This limits its effectiveness in certain procedures.
What is the EBU 4 guide routinely used for?
Left coronary intervention
This guide is commonly utilized in interventional cardiology.
True or False: The Ikari left guide is effective for rapid angiography prior to PCI in STEMI.
True
Its design facilitates quick imaging and intervention.
