DIAGNOSTIC

CATHETERS-
CORONARY
ASWIN R.M.

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History

Classification

Catheter structure & Materials

Femoral Catheters

Radial Catheters

Cathetrs for IMA & graft

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FIRST CARDIAC
CATHETERISATION
■ In 1929
■ Werner Forssmann
■ Rubber catheter
■ Through his own antecubital
Vein
■ Upto the pulmonary artery

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HISTORY OF CORONARY
CATHETERIZATION
Selective cannulation of coronory or injection of
dye into coronary arteries were considered unsafe
■ Random "Brute Force" Approach – Upto 50 cc contrast in
1-2 sec
■ Phasic injections – electronic pressure injectors timed
with cardiac cycle for intentional diastolic injection
■ Methods of reducing cardiac output
– Acetylcholine arrest
– Elevation of intrabronchial pressure
■ Occlusion aortography
■ Differential opacification of aortic stream

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FIRST SELECTIVE CORONARY
ANGIOGRAM
■ Was an accident
■ Dr Mason Sones in 1958
■ After withdrawing a catheter
after ventriculogram cannulated
the RCA unknowingly
■ When contrast was injected for
an aortogram selective
opacification of RCA noted
■ Designed Sones catheter and
popularized the technique
■ Several preformed catheters
were later designed.

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DIAGNOSTIC CATHETERS

Angiography

Pressure monitoring

Oxygen saturation monitoring

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ANGIOGRAPHIC CATHETERS
Flush Selective

• No selective canulation of • Selectively canulation of vessel

vessel • Rotational stiffness enough to
• Contrast injection through selectively seek a vessel orifice
multiple side holes • Enough flexibility to advance
• Uniform injection without recoil into the vessel
• Tip usually rounded to avoid • Flow rate not important as
entering a vessel and to keep contrast volume used is less.
shaft in centre • Ex – preformed coronary
• Ex Pigtal catheter catheters

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 CORONARY CATHETERS

Diagnostic Guide

• Thicker shaft • Thinner shaft

• Internal dm • Internal dm
Smaller larger
• Tapering tip • Non tapering tip
• Less Reinforced • More Reinforced
construction ( 2 construction ( 3
layers) layers)

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IDEAL CHARACTERISTICS OF
A CATHETER
■ Better Torque Control
– Increase Outer diameter
– Reinforced construction
■ Pushability
– Increase Outer diameter
– Stiffer Material
– Decreasing overall part length
■ Flexibility
– Decrease Outer diameter
– Material with less modulus of elasticity
– Increasing overall part length
■ Trackability
■ Radio-opacity
■ Atraumatic Tip
■ Low Surface frictional resistance
■ Kink resistance
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PARTS

A) TIP LENGTH – Increased length offers more

stability in target vessel at the cost of
maneuverability in the parent vessel.
B) PRIMARY CURVE – angle of the target vessel
from its parent artery.
C) SECONDARY CURVE -- width of the parent
vessel.
D) TERTIARY CURVE –normal curvature of the
parent vessel.
E) CATHETER LENGTH – Usually 100 or 110 cm

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Over bent & Under bent
catheters
Over bent-
Angle of catheter tip is smaller outside
the body, than inside
■ Shape of overbent inside body-easy to
predict
■ Easier to manipulate

Underbent-
Angle of catheter tip is larger
outside the body than inside
■ Difficult to manipulate, shape
difficult to predict
■ Difficult to do deep engagement 11
SIZE MEASUREMENT:
FRENCH CATHETER SCALE:
The French catheter scale is commonly used to measure the
outer diameter of cylindrical medical instruments
D(mm) = Fr/3
Most commonly in adults -- Diagnostic Catheters of 5 – 7 Fr
size

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WALL THICKNESS
■ Thick walled-
– Better pushability and torque transmission
– Accentuates pressure waveform-systolic
overshoot & diastolic dips.
■ Thin walled _
– Improves monitoring, blood sampling & flushing
abilities, decrease thrombogenicity.
– Disadvantage – less torque control, not suitable
for high pressure injection.

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CATHETER MATERIALS
Angiographic catheters made from Synthetic and
semisynthetic Polymers
Dacron
Nylon
Polyvinylchloride (PVC)
Polyethylene (PE)
Fluoropolymers (PTFE) (TEFLON)
Polyurethane (PUR)
Silicon

Radio opacity by incorporating Ba , Bi , Ir

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CHARACTERISTICS
Flexibility & Stiffness (Elastic coefficient)

Friction coefficient – Vascular Trauma

Thrombogenicity

Tensile Strength (Memory)

Moisture & Drug absorption

Mouldabilty
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DACRON
■ Very maneuverable & flexible.
■ Covered by polyurethane coating – reduce vascular
trauma.
■ Some have Nylon core-increase bursting pressure
■ Nylon – great mechanical & physical strength,
reduced friction coefficient – achieve high flow rate
of fluids
■ Eg- NIH Catheter , Original Sones Catheter.

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POLYURETHANE
■ Excellent memory
■ Softer than polyethylene or Teflon – Less vascular
trauma
■ Increased thrombogenicity
■ Reshaped if immersed in boling water.
■ Eg – pigtail angiographic (cordis) catheters & original
judkins catheters.

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POLYETHYLENE
■ Stiffness inbetween Polyurethane & Teflon.
■ More Thrombogenic than PVC, polyurethane
■ Heat Mouldablity good
■ Eg – pigtail angiographic catheters, judkins
catheters

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POLYVINYL CHLORIDE

■ Softest & flexible among all

■ High friction coefficient- spasm.
■ Increased thrombogenicity.
■ Very poor tensile strength (memory)
■ Cant be reformed.
■ Most hydrophilic.
■ Drugs absorbed- NTG, insulin,
diazepam,thiopentone.
■ Eg- Balloon-tip flow directed catheters.

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TEFLON
■ Stiffest – no suitable for selective catheters
■ Poor memory.
■ Low friction coefficient.
■ Eg – Brockenbrough catheters, transducer-tip
catheters & introducer sheaths.

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CATHETER LAYERS
Outer Layer

Outer coating to reduce

friction and thrombogenisity

Reinforcement –usually
stainless steel braid
Determines torque and Kink
resistance

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TIP & HUB
■ TIP: Tapering tip for
Diagnostic catheters
■ HUB: Metal or plastic, larger
than catheter, tapered hubs –
easier insertion of guidewire.

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SIDE HOLES
Advantages
 Prevent catheter damping (occlusion of the coronary
ostium)
 Allow additional blood flow out of tip, to perfuse the
artery.
 Avoid catastrophic dissections in the ostium of the
artery
 Avoids Disengagement during Injections

Disadvantages
 False sense of security because now, aortic pressure,
and not the coronary pressure is being monitored.
 Suboptimal opacification
 Makes catheter tip weak - kinking at side holes

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 Catheter Choices

Graft & IMA

Left Catheters Right Catheters Universal Universal Radial
Catheters
• Judkins Left • Judkins Right • Multipurpose • Tiger • RCB
• Amplatz Left • Amplatz Right • Sones • Jackey • LCB
• Right Coronary • Castillo • Kimney • IMA
3D • Etc.. • IMA VB-1

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Catheter choice and size
selection
Access

Height &
Operator
weight

ACS vs Catheter
Age
Elective Choice

Native
coronory Anatomy
/ post of aorta
CABG
Target
vessel

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 Catheters for
Native coronaries

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JUDKINS CATHETER
■ Melvin Judkins in 1967
■ Preformed catheter
■ Primary and secondary curve
■ Tapered tip with end hole
■ Designed for femoral route
■ Little manipulation needed if
used from femoral route

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 JUDKINS CATHETER
 Size 3.5to 6 by most
companies
 Length 100 cm
 4-7 French available
 Size 4 usually used
 Right radial access
 0.5 less size used for
left Coronary
 1 larger size for right
Curve length = distance between P Coronary
(primary curve) & S (secondary curve)
 In aortic aneurysms heat
modification for size 7 to
10 done

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ENGAGEMENT
■ Left Judkins

■ Right Judkins

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30
Aortic width

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AMPLATZ CATHETER
■ Original catheter by Kurt Amplatz
■ Austrian Radiologist
■ 1967
■ Right and Left comes in 3 sizes
usually
■ 1 ,2,3 with increasing curvature
■ 0.75 size , increments of .5 and 4
size also available for AL

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AMPLATZ LEFT
■ Coronory ostia out of conventional judkins
Like high and posterior origin
■ It can selectively canulate LAD or LCX if short
left main stem
■ Separate origins of left anterior descending
and left circumflex coronary arteries.
■ High anterior right coronary arteries (RCAs) or
Shepherd’s Crook RCA.

While engaging the left coronary pushing the catheter will cause
disengagement and pulling the catheter will cause deeper engagement of
the Amplatz catheter, due to its peculiar curve

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AMPLATZ RIGHT
■ Amplatz right coronary catheter can be
used to cannulate right coronary arteries
with abnormal, usually, an inferior origin
or high anterior

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Coronary anatomy Variation
Coronary ostial location:
 High
 Low
 Anterior
 Posterior

Coronary ostial orientation (take offs):

 Superior
 Horizontal
 Inferior
 Shepherd’s crook (RCA’s only)
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Coronary Ostial take offs

Horizontal Inferior Superior Shepard crook

RCA

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SUMMARY
Normal origin And Course JR4
Anterior ectopic origin AR, AL , Hockey stick
Inferior ectopic origin with inferior course MP
Superior ectopic origin from ascending MP
RCA
thoracic aorta with inferior course
Superior course IM 3DRC
Tortuous bend anatomy , posterior takeoff 3DRC
Anomalous RCA from left sinus JL 5,6 AR 2,3,
Normal origin and course Jl4
Large ascending thoracic aorta JL 5,6
Small Acsending thoracic aorta JL3 , 3.5
LMCA
Anomolous origin from right sinus AR
Anomolous origin of LCX from right sinus JR AR MP
Separate origin of LCX LAD AR
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 MULTIPURPOSE CATHETER
■ Initial multipurpose catheter by
Schoonmaker & King
■ In 1974
■ Developed to avoid the need of 3
separate preformed catheters for
both coronaries and ventriculography
from femoral route
■ Similar to the Sones catheter
■ Polyurethane catheter
■ Single curve with straight tip an end
hole and two side holes.

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MULTIPURPOSE CATHETER

■ A bend – hockey stick with straight tip 120 degree curve

■ B bend -- gradual 90 degree curve

■ MP A-1 : 1 end hole only

MP A-2 : 2side holes ,1end hole
MP B-1 : 1 end hole only
MP B-2: 2 sideholes and an end hole

■ Use: CAG – Both native vessel and graft , Ventriculography , Right heart
catheterization
■ With more specialized catheters its use has decreased

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Other Catheters

3DRC Castillo

Gensini Sones
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RADIAL ACCESS
Less bleeding and vascular complications

Cost effective

Patients preference

Early discharge

Anticoagulants can be continued

More learning curve

More radiation to operator

Limits guide catheter size

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RADIAL ACCESS
Standard catheters are all designed to to be used
from femoral route

High learning curve

High Incidence of artery going for spam – hence

catheter exchanges should be minimized

Subclavian tortuosities, Radial loops, Anomolous

High origin of radial artery

Sheath and catheter size limitaiton

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RADIAL ACCESS
■ Course of catheter

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Difficulty passing to aorta

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DIAGNOSTIC CATHETERS -
RADIAL APPROACH
■ Two catheter
– JR & JL
– AR & AL
■ Single Catheter
– Standard femoral catheters – JL , AL , AR
– Universal /Bilateral catheters – Ex:
■ Tiger , Jacky , Sarah (Terumo)
■ Kimney (Boston Scientific)
■ MAC 30-30 ( Medtronic)
■ Ultimate Radial 1 & 2 (Merit medical)
■ Bilateral Brachial (Cordis)

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Coronary Speciifc or Universal
??
Advantages Disadvantages

• No exchange • Learning curve

• Less flouro time • Coaxial engagement
difficult – Increased
ostial trauma
• Inferior take offs –
deep seating
• Inferior take off RCA –
S elective Conus
branch canulation

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Tiger & Jacky Catheter
■ Both RCA and LCA with one catheter that can
potentially:
– Limit catheter exchanges
– Shorten procedure and fluoroscopic time
– Lower cost per procedure
■ Side hole
– Avoids intimal dissection during injection
in non coaxial engagement
– prevents Kicking off during injections and
■ Available in 5F & 6 F
■ Nowadays used for transradial diagnostics
more than any other catheter

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1 side hole 2 side holes
Size 4 & 4.5 Size 3.5 & 4 (Sarah)
Length 100 & 110 cm Length 100 & 110 cm
Rarley Coaxial Amplatz type tip
Selective canulation of conus Better canulation
branch can occur Ventriculography

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 HEIGHT
■ Very tall patients 100 cm
catheters cannot reach upto
coronary ostia
■ Solution
– 110 cm Diagnostic
catheters
– Multipupose catheter
with 125 cm
– If radial prefer Left
Radial access
– High radial puncture

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WEIGHT
■ Obesity
– Diaphragm moves cephalad
– Heart axis horizontal
– Short ascending aorta
– Counter clockwise rotation of coronary ostia
– RCA more anterior and LMCA more posterior
take off
– If radial Left Radial has advantage over right

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POST CABG

■ Vessels to tackle LIMA RIMA Grafts (ReSVG or

Arterial)

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SVG or ARTERIAL GRAFTS
■ Usually Anterior surface higher up
from sinus of vasalva
■ Left coronary grafts - left anterior
surface with circumflex grafts higher
up
■ Right coronary grafts -right anterior
surface
■ Ring markers often placed otherwise
have to rely on surgeons report and
previous angios ■ A – dRCA / dLCX ( in L dominant
systems)
■ JR catheter mainstay in graft angios
■ B- LAD

■ C- Diagonal

■ D- LCX / OM / Ramus

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Catheter selection
■ Right Grafts
– Primary choice - MP
– Alternative – JR , RCB , AL
■ Left Grafts :
– Primary Choice – JR4 , AL1
– Upward trajectory may require - LCB , IM , HS
– More anterior origin – AL , HS > JR , LCB , MP

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BYPASS CATHETERS
■ RCB
– Resembles JR4 with a tip curved >90
degree
■ LCB
– Primary curve similar to JR4 ( 90 degree )
but secondary curve more acute ( 70
degree)

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POST CABG
LIMA & RIMA
 Normal – IM , JR4
 Origin from vertical portion
of subclavian artery- JR4 ,
 If radial - left radial approach IM
is more suitable in patients
with LIMA graft
 If Both LIMA and RIMA is to
be canulated JR4 – can avoid
catheter exchange

LCB
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Internal mammary catheter

■ Resembles Judkins right except for

tighter primary curve (80degree) and
longer tip

IM VB-1

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Other Catheters for IMA
■ BARBEAU

■ RIMA

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LIMA CANULATION
■ Ease = Femoral = LRA>>RRA
■ Techniques for LIMA cannulation with IMA catheters from RRA
are described
■ All of them based on passing a guide wire upto left elbow and
catheter passed over wire

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LIMA CANULATION
■ Special Catheters for RRA LIMA also
designed
■ Ex: Yumiko Catheter

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Right Gastroepiploic
■ Usually to PDA
■ Visceral angiographic catheter
like cobra can be used
■ Alternatively JR IMA
■ For angiography non selective
injection of coeliac trunk done

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SUMMARY
Pattern of Coronary Suggested primary
Grafting approach
LIMA LRA

LIMA + RIMA RRA or Femoral

LIMA + RIMA + RA Femoral

LIMA + ReSVG(s) LRA

ReSVG(s RRA or LRA

Burzotta F et al. CCI 2008;72:263-272

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THANK YOU

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