Selection and Use of Basic

Equipment: Guide Catheters,

Wires and Balloons

Michael J. Cowley, MD, MSCAI

NIC Mid-term Meeting, Hyderabad

April 15, 2016
Basic Guiding Catheter Functions

Supportive conduit for advancement

of guidewires and devices
Vehicle for contrast injection

Measure blood pressure

Important Guiding Catheter Features

Atraumatic tip

Proper preformed shape

co-axial with vessel

Torque control

Kink resistance

Radiopacity
Guide Catheter Construction
 Guide Catheter Sizing

Diameter Lumen size required

Access site & prox coronary size
5-7 F femoral; 5-6F radial

Length 100 cm standard

>100 cm in tortuous aorta or
radial access in tall patient
<100 cm for distal sites (snake
graft, tortuous IMA)
Proper Left Guide Catheter Position
Guide Catheter Selection
Aortic Configuration
Normal
Dilated
Narrow or Short
Coronary Orientation (take off)
Normal, Upward (high), Downward
SVG Orientation
RCA: horizontal or downward
LCA: Horizontal or superior
Guiding Catheter Support
 Possible Solutions when the RCA
Originates More Anteriorly

Right Judkins Right Judkins Left Amplatz or Left Amplatz or

or Hockey Stick Hockey Stick Left Judkins
(out of plane)
 Guide Catheter Options for Difficult
Right Coronary Cannulation

Hockey Stick Amplatz EBU or Left LIMA or

Graft XBRCA

LIMA catheter useful for upward - oriented RCA origin or

Shepherds Crook Curve
 Guide Selection for Vein Grafts

Left Bypass; Hockey

Stick or Amplatz Left
Multipurpose;
Right Bypass

Right Judkins or
Multipurpose Hockey Stick

Right Judkins (JR4) will cannulate most grafts

Physics of Guide Catheters for Left Coronary
Artery in Transfemoral and Transradial PCI

Ikari et al J Invas Cardiol 2005;17:636-641

Radial vs Femoral Access
Guide Selection and Use Influence Support

h q Angle provides greater Backup

Support
Backup Force with Various Guide Shapes

JL JL deep BL 3.5 IL 4 IL4 Power

 Guide Catheter Support
Approach
Femoral > L Radial > R Radial
Power support angle ( q )
Contralateral aortic wall angle q
Deep seating vs power curves
XB, EBU, Amplatz, Ikari
Coaxial alignment
Larger French size
Guide Wires
 Coronary Guide Wires
Basic Characteristics

Steerable
Deliverable

Atraumatic Adequate Smooth

Tip Rail Support Coating

Tip Central Core Lubricious Coating

Polymer sleeve or Stainless steel Silicone
Coil-Spring Tip Durasteel PTFE
Platinum,Tungsten, steel nitinol/Elastinite Hydrophilic
 Guidewires
Tip Coil with Shaping Ribbon Design
 Guidewires

Core-to-Tip Design
 Guidewires
Smooth Taper Core Grind Design
 Guidewires
Core Diameter
Diameter affects flexibility, support and torque

Smaller Diameter: More Flexibility

Larger Diameter : More Support & Torque

 Guidewires
Core Taper

Longer taper: better wire tracking, less prolapse

Shorter taper: better support, more prolapse

 Core Taper

Short tapers produce h longitudinal

support but also h tendency to prolapse

Prolapse
 Core Taper

Long or gradual tapers provide greater

tracking and less tendency to prolapse

Successful
Tracking
 Guidewires
Core Material
Affects flexibility, support, steering and tracking

Stainless Steel

Nitinol/Elastinite
 Guidewires
Core Material

Stainless steel
Original core material technology
Good support, push force and torque
Less flexible than newer core materials
 Guidewires
Core Wire:
Ground and tapered on the distal end to
increase flexibility
Coil Spring:
Typically soldered to core wire at point where
inside diameter of coil spring matches the
outside diameter of the core wire
 Guidewires
Core Material

Nitinol / Elastinite
Super-elastic alloy designed for kink resistance
Excellent flexibility and steering
Work-Horse Guide Wire Characteristics

Intermediate Core Diameter

Gentle Core Taper
Resilient Core with good torque control
Soft Tip
Coils or Covers
Smooth Coating
 Ideal Workhorse Wire

Soft, flexible and atraumatic tip

Excellent torque transfer (1:1)
Good tactile feel
Excellent steerability and pushability
Supportive but tracks well in tortuous vessels
Facilitates balloon and stent delivery
 Coronary Guidewires
Workhorse
HTF, BMW, Prowater, Runthrough, ATW
Hydrophilic
Whisper, Choice PT
CTO
Fielder XT, Miracle Bros, Confianza
Extra Support
 Coronary Guide Wire Characteristics
Unfavorable Features

Steerable
Deliverable

StiffAtraumatic Adequate
Increased Smooth
Hydrophilic
Spring
Tip Tip Rail
Rail Support
Support Coating
Coating

Dissections & Straightening Perforation

Perforations Artifacts
Pseudo-lesion

Safian et al
Balloon Angioplasty
Balloon Angioplasty
Current Clinical Usage

Pre-dilation
Stent Deployment
Post-dilation
Anatomy of a Balloon Catheter
Over-The-Wire (OTW) Balloon Catheter

Monorail (Rx) Balloon Catheter

 Balloon Catheter Performance
Handling Inflation
Trackability Compliance
Pushability Compliant
Crossability Semi-compliant
Entry profile Non-compliant
Crossing profile Dilating Force
Nonimal Pressure
Rated burst pressure
 Balloon Angioplasty
Key Performance Characteristics

Compliance
Dilatation force
 Balloon Angioplasty
Compliance

The rate of the change in balloon diameter over

a range of inflation pressures
Determined in unconstrained environment
Does not address resistance to expansion
Balloon Materials & Performance
Compliance

Compliant
Diameter (mm)

Semi-Compliant

Non-Compliant

0 Atmospheres (ATM)
 Balloon Compliance
Material Growth Above
Nominal

Compliant Polyolofin ~20%

Semi-compliant Polyethylene or ~10%

Nylon

Non Compliant PET ~0-5%

 Balloon Performance
Compliance Chart
3.0 mm Balloon
Derived from bench testing
In vitro, 37 in water bath
Unreliable in vivo
Significant overestimation of actual
MLD by IVUS
~20% less than stated chart size
 Balloon Compliance Charts
3.0 mm Balloon
3.6
Quantum Maverick Sprinter
3.5
3.4 RB
Diam (mm)

3.3 RB
3.2
3.1 RB

3 N N N
2.9
2.8
2.7
2.6
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
 Balloon Angioplasty
Materials & Performance

Dilatation force
The radial force exerted by the balloon on the
coronary lesion or metal stent
Dilatation force is a function of
Inflation pressure
Balloon material (compliance)
 Growth is more significant as pressure increases
Balloons grow in areas of least resistance

Low and focal growth as pressure increases

Designed for dilatation of calcified or resistant lesions
 Balloon Performance
Dilatation Force (Straw Test)
Semi-compliant
Low-compliant
Non-compliant
Dilatation Force

NC LC
SC

0 2 4 6 8 10 12 14 16 18 20 22 24

Pressure (ATM)
 Materials & Performance
Compliant & Semi-compliant Balloons

Better flexibility & trackability

Better cross and recross performance
Limited durability
Increased diameter and longitudinal
growth variance
Limited dilatation force
 Materials & Performance
Compliant & Semi-Compliant Balloons

Used for Pre-dilatation

Gain lesion access/ prepare
vessel for stent
Determine lesion
length/diameter
Determine lesion morphology

Trade-offs
Potential growth outside lesion
Unwanted vessel expansion
 Materials & Performance
Non-Compliant Balloons

Durability
Focused radial force to lesion / stent
Less diameter / longitudinal growth variance
Reduced flexibility, trackability
Limited cross and re-cross performance
Limited sizing flexibility
 Materials & Performance
Non-Compliant Balloons

Used for Post-dilatation

Maximum dilatation force

Focal stent expansion

Lowest longitudinal growth

 Device Delivery Problems
Inability to Pass Balloon/stent around bend

Better Guide support

Stiffer guide wire
Buddy wire
Guideliner
More flexible stent
Shorter stent
 Pre-PCI Planning

Access site and guide catheter selection ?

Guidewire characteristics desired ?
Strategies to be used
balloon, modified balloon, direct stent ?
BMS, DES ?
Alternative equipment / techniques (Plan B)
 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 )

 Balloon Angioplasty
Role with Stenting

Pre-dilatation
Gain lesion access / prepare vessel for stenting
Determine lesion length / diameter
Determine lesion morphology
Post-dilatation
Ensure full stent expansion / apposition of stent
Optimize Minimum Lumen Diameter (MLD)
 Summary

Proper choice of equipment facilitates

best results with PCI:
Shortens procedure times
Improves succss rates
Reduces complications and adverse
events
 Selection and Use of Basic
Equipment : Guiding Catheters,
Wires and Balloons

Michael J. Cowley, MD, MSCAI

Professor of Medicine
Virginia Commonwealth University

Feb 19, 2016