1. SCAI Interventional Cardiology Fall Fellows Course 2012 Selection and Use of Basic Equipment : Guiding Catheters, Wires and Balloons John S. Douglas Jr, MD Professor of Medicine Emory University School of Medicine December 4, 2012 8:30 am

2. ACCF / SCAI Interventional Cardiology Board Review 2010 Selection and Use of Basic Equipment : Guiding Catheters, Wires and Balloons John S. Douglas Jr, MD Professor of Medicine Emory University School of Medicine August 22,2010 8:10 am

3. Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial RelationshipCompany Grant/Research Support J&J,Medtronic,Boston Sci,Abbott,MedicinesCo Consulting Fees/Honoraria None Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None

4. Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial RelationshipCompany Consulting Fees/Honoraria None Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None

5. The Guiding Catheter : The Most Underrated Asset to Coronary Angioplasty – Commentary by Bernhard Meier MD, J Invasive Cardiology 2005 ;17:642-643

6. Basic Functions of a Guiding Catheter Provide a supportive conduit for advancement of guidewires and devices Serve as a vehicle for contrast injection Measure blood pressure

7. Important Characteristics of a Guiding Catheter Atraumatic tip Proper preformed shape ( co-axial with vessel) Torque control Kink resistance Radiopacity

9. Guide Catheter Construction Primary Curve Secondary Curve tip

10. Curve Length 3.0 4.0 5.0 Judkins Left P S P = Primary Curve S = Secondary Curve Curve Length = P-S distance (cm)

11. Guide Catheter Dimension Lumen Requirement Access site and proximal coronary artery size 5-7 F femoral ; 5-6F radial artery Diameter 100 cm standard > 100 cm in tortuous aorta or radial access in tall patient < 100 cm for distal sites (snake graft, tortuous IMA) Length

12. Properly Sized Left Extra Backup Coronary Catheter Femoral

13. Left Amplatz Guide Catheter LCX A Catheter Associated with Increased Complications

14. Possible Solutions When the Right Coronary Originates More Anteriorly Right Judkins or Hockey Stick Right JudkinsHockey Stick or Left Amplatz Left Amplatz or Left Judkins (out of plane)

15. Possible Solutions to Difficult Right Coronary Guide Catheter Selection AmplatzHockey StickLeft Venous Bypass Graft Arani or XBRCA

16. Catheter Selection For Saphenous Vein Grafts MultipurposeMultipurpose or Right Judkins Hockey Stick Hockey Stick or Amplatz Left

17. Douglas JS Jr,J Invas Cardiol 2011, 23: 434-437

18. Advantages of Radial Access Reduced Bleeding Fewer Access Site Complications Improved Patient Comfort Shortened Time to Ambulation No Warfarin Interruption Applicability to Outpatient PCI

19. The Physics of Guiding Catheters for Left Coronary Artery in Transfemoral and Transradial Intervention Ikari et al J Invas Cardiol 2005;17:636-641

25. Guide Catheter Related Complications Air Atheroma Thrombus Coronary Artery Subclavian or IMA Aortic root Abdominal Aorta Iliac Artery EmbolizationDissection

26. Guide Catheter Scraping of Aortic Debris in 1000 Patients Aortic Debris retrieved from > 50% of guide catheters Keeley et al J AM Coll Cardiol 1998; 32:1861-1865 Percent with Debris ALARHSLIMAVLMPJL Catheter Type 3+ Debris 1 or 2+ Debris JR 0 20 40 60 80

27. Guide Catheter Use Aspirate vigorously ( atheroma or thrombus “scooped up”from the aorta ) Insist on bleed back (prevent air embolus) Avoid blood standing in guide (flush frequently) Proximal or ostial disease – Avoid Amplatz – Care with side holes and deep engagement

28. Air Embolus Acute Ischemia after Coronary Injection Transient Symptoms Large Diameter Catheters No “bleed back” Air visible in coronary Clinical FeaturesAssociated Conditions Treatment: Support Circulation, Aspirate air, Coronary Injection,Hyperbaric Oxygen

29. Ischemia Due to Obstructing Bubble Muth et al NEJM 2000 ; 342:476-482

30. Chest Pain, ST Elevation, Shock, VF, CPR Occurred

31. Patient Back to Normal in 15 Minutes

32. 11/14/12

34. Atheroembolus Unrelenting Ischemia after injection Slow flow in recipient vessel Calcified Aorta Abdominal aortic atherosclerosis or aneurysm Peripheral Vascular Disease Clinical FeaturesAssociated Conditions Treatment: Supportive, Treatment of Ischemia

35. Guide Catheter Dissection Angiographic evidence of RCA or LM dissection Ischemia and hemodynamic collapse Left Main Disease Amplatz Catheters Difficult Coronary Intubation or Balloon or Stent Withdrawal Poor Fluoroscopic Visualization Clinical FeaturesAssociated Conditions Treatment: CABG; Emergency Stent

36. Left Main Injury Following LAD Stent

37. Left Main Injury Treated with Stent Implantation

38. Basic Coronary Guide Wire Characteristics Adequate Rail Support Atraumatic Tip Smooth Coating Steerable “Deliverable”

39. Guidewire Construction Central Core Stainless steel Durasteel™ nitinol/Elastinite® Tip : Polymer sleeve or Coil-Spring Tip Platinum Tungsten Stainless Steel Lubricious Coating Silicone PTFE Hydrophilic 3 basic components

43. Core Diameter Diameter affects flexibility, support and torque Smaller Diameter = More Flexibility Larger Diameter = More Support & Torque

44. 44 Core Taper Longer taper- superb wire tracking, less prolapse Shorter taper- longer segments of consistent support, more prolapse

45. 45 Core Taper Abrupt or short tapers produce a core which provides greater segment length of support but also greater tendency to prolapse Prolapse

46. 46 Core Taper Broad, gradual or long tapers produce a core which offers greater tracking and wire which prolapses less Successful Tracking

47. Core Material Affects flexibility, support, steering and tracking Stainless Steel Nitinol/Elastinite® High Tensile Strength Stainless Steel/Durasteel™

48. 48 Core Material Stainless steel – Original core material technology – Good support, push force and torque – Less flexible than newer core materials

49. 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

50. Work-Horse Guide Wire Characteristics Intermediate Core Diameter Gentle Core Taper Resilient Core with good torque control Soft Tip Coils or Covers Smooth Coating

51. Change Coronary Guide Wire Characteristics Adequate Rail Support Atraumatic Spring Tip Smooth Coating Steerable “Deliverable” Stiff Tip Dissections & Perforations Increased Rail Support Straightening Artifacts Hydrophilic Coating Perforation

52. Pseudolesion Safian et al

53. Special Guide Wire Problems ProblemSolutionCompromise Total Occlusion - Tapered 0.009” wire and/or hydrophilic coating Less rail support with 0.009” wire, wire perforation -BluntStiff TipIncreased Dissection and Perforation

54. Device Delivery Problems ProblemSolutionCompromise Unable to deliver a balloon or stent around a corner Stiffer wire or buddy wire or flexible stent or better guide or Guideliner Cost; straightening artifacts; increased risk

55. Balloon Angioplasty Advantages Limitations Broad Applicability Low Cost Repeatable Suboptimal Acute Results in Complex Anatomy Restenosis Rarely “Stand Alone”

56. Balloon Angioplasty Alone Treatment of focal in-stent restenosis ( especially BMS or multiple layers ) Anastomosis lesions soon after surgery Bifurcations ( treatment of daughter limb ) Small vessels ( <2mm )

57. Bigger is Better – Restenosis Rates of Quintiles of Luminal Diameter Following Coronary Intervention Kuntz et al JACC 1993;21:21 Restenosis % 0 10 20 30 25 50 60 40 3.5 3.02.52.01.5 Post Procedure Lumen Diameter (mm)

58. Issues in Balloon Sizing Angiography most commonly used but underestimates vessel size Balloon oversizing leads to increased dissections (Roubin et al 1988) Balloon Compliance must be known

59. Balloon Modifications Cutting balloon : 3 or 4 atherotomes ; useful in resistant lesions, recoil ( aorto-ostial ),ISR, to prevent balloon slippage (melon seeding ) AngioSculpt Scoring Balloon : 3 rectangular nitinol spiral struts may reduce dissection Drug coated balloons may reduce restenosis in peripheral applications and in DES restenosis

60. Scheinert et al Circulation 2006

61. Important Basic Issues to Always Discuss Prior to the Case Access site and guide catheter selection ? Guidewire characteristics desired ? Strategies to be implemented ( balloon, modified balloon, BMS, DES, etc ) ? What complications are likely as the result of application of these basic PCI strategies ? Guide wire perforation

62. THANK YOU