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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3585_Библиотеки_им_академика_М_И_Перельмана
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1.3 Guiding Catheter
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Fig. 1.12 PCI for CTO of the RCA after switching to a guiding cath-
eter from Group A. (a) The tip of the guiding catheter has been engaged
deeply, so the catheter will not be pushed back when a guidewire is
manipulated. (b) CAG reveals that the catheter is coaxial with the RCA
and its shaft is pressed against the contralateral wall of the sinus of
Valsalva. Dotted curves show the cusps and the aortic wall
Fig. 1.13 Images of a Group A guiding catheter that has been optimally engaged by pushing (compare with deep engagement in Fig.1.12). (a)
Before injection, the pressure waveform and the position of the catheter tip indicate that the catheter is engaged optimally. (b) After injection
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Sinus of Valsalva
Sinus of Valsalva
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1 Mitsudo’s PCI Techniques forCTO
Size of the Catheter Tip Curve
The curve of the catheter tip is the optimum size if the distance between its tip and shaft is slightly shorter than the
distance between the RCA ostium and the contralateral wall
of the sinus of Valsalva (Fig.1.14). Since contrast-enhanced
CT makes it possible to measure the dimensions of the sinus
of Valsalva, determining the catheter tip curve size based on
measurement of the sinus is recommended at centers where
contrast-enhanced coronary CT is routinely performed
before PCI.The same method can be applied to determine
the optimum size of the curve of a guiding catheter for the
left coronary artery (LCA). Since I usually omit pre-PCI
coronary CT, I initially try to engage a guiding catheter with
an average-sized tip curve. If this initial attempt fails due to
the wrong curve size, I then modify it. In principle, I choose
a guiding catheter with a curve of such a size that the catheter
becomes disengaged when it is advanced slightly.
My rst choice is the BriteTip AL 1 ST for male
patients and the Launcher SAL 1 for female patients.
However, the size of the sinus of Valsalva varies among
individuals, and some patients have an unexpectedly large
sinus. At my center, BriteTip® catheters are available in
sizes up to AL3.
Selecting a Guiding Catheter with or Without Side
Holes and Management of a “Wedged” Waveform
In principle, I never use a guiding catheter with side holes for
the RCA or the LCA.This is because the pressure waveform
is not damped even if such a catheter becomes wedged, making it difcult to become aware of the increased risk of ostial
injury, so that injury is more likely to occur. Let us consider
the case where the catheter is not initially wedged, but subsequently the pressure waveform shows a “wedged” pattern
when an Amplatz left-type guiding catheter is engaged. A
good solution is to advance the guiding catheter by about 2
to 3 cm while monitoring the waveform without checking
uoroscopic images. This will usually result in slight disengagement of the catheter tip, and the wedged waveform will
be normalized. If this maneuver fails, the guiding catheter
should not simply be advanced further, but should be gently
rotated counterclockwise and then slowly advanced under
uoroscopic guidance. This will lead to disengagement of
the catheter with normalization of the pressure waveform.
If the guiding catheter has a relatively large tip curve
compared with the size of the sinus of Valsalva, the pressure
waveform may show a wedged pattern when the catheter is
engaged, while the waveform often improves after exchanging the catheter for another catheter with a curve that is one
size smaller. If a catheter with a smaller curve is not available, it will be necessary to (reluctantly) exchange it for one
with side holes.
I create side holes in guiding catheters by using an 18-G
injection needle to make two holes on the medial side of the
second curve of the catheter. Each hole is created slowly and
carefully by rotating the needle to-and-fro, rather than simply
pushing it into the catheter (i.e., by gradually removing small
particles of catheter material with the bezel of the needle). A
hole created in this way remains patent for a long time. The
second hole should be created in the same way by using a fresh
needle. After creating the two holes, the tip of the catheter
should be covered with the ngertips, and the catheter should be
vigorously ushed with saline to completely remove all debris.
Launcher SAL 1 BriteTip AL 1 ST
Fig. 1.14 Optimal size of the guiding catheter tip curve relative to the
sinus of Valsalva. Ideally, the distance between the tip and the shaft of
the guiding catheter is slightly shorter than the distance between the
RCA ostium and the contralateral wall of the sinus of Valsalva. A
female patient of short stature often has a small sinus of Valsalva (a),
and the Launcher SAL 1 is generally optimal for such patients. A male
patient of medium stature often has a medium-sized sinus of Valsalva
(b), and the BriteTip AL 1 ST is usually optimal
Pull Back to Advance the Tip and Push Forward to
Disengage the Tip
As I mentioned before, you should pull a guiding catheter
back slightly to advance the tip into the target coronary
artery and should push an engaged catheter forward to disengage it. However, you may sometimes nd that pushing a
deeply engaged guiding catheter forward fails to move its tip
toward the ostium.
If this happens, you should initially try to advance the guiding catheter slightly while gently rotating it counterclockwise.
This maneuver may succeed in disengaging the catheter tip
a
b
1.3 Guiding Catheter
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without slipping it from the RCA ostium, although the catheter becomes slightly unstable. If this maneuver actually results
in deeper engagement of the guiding catheter, you can pull
the catheter back while gently rotating it counterclockwise
Removing the Guiding Catheter via the Femoral Artery
When removing a guiding catheter with its tip at the level of
the aorta, you should utilize an inner sheath catheter and a
guidewire to minimize stress on the aortic wall.
until the tip just becomes disengaged. If the catheter is subsequently advanced slightly, the tip will often become stable
again within the sinus of Valsalva, resulting in good engagement. If a guidewire has been advanced into the RCA from the
guiding catheter, you should push it in slightly deeper and then
advance the catheter. This maneuver will result in stable location of the catheter tip within the sinus of Valsalva.
1.3.1.3 Short-Tipped Judkins Catheter or Extra
Backup Catheter fortheLCA
Among Judkins-type guiding catheters, I recommend using
short-tipped catheters (preferably short-tipped catheters with
a small rst curve) for the LCA (Fig.1.16). As early as 1985,
Hartzler recommended the use of a short-tipped Judkins
guiding catheter.
Removing the Guiding Catheter from the RCA Ostium
at the End of the Procedure
To remove a guiding catheter from the RCA at the end of the
procedure, you should never simply pull the catheter back
because removing it in this way is likely to cause ostial injury.
As shown in Fig.1.15, you should initially push the catheter
further in while rotating it counterclockwise to disengage the
tip. After the catheter tip has come out of the RCA ostium,
you should slowly withdraw the entire catheter until the tip
reaches the level of the aorta. If this method of disengaging the
catheter fails, you can also slowly pull the catheter back while
rotating it counterclockwise to disengage the tip. With the latter method, the tip of the catheter will go directly up to the
level of the aorta, and you should then keep the tip at that level.
A short-tipped Judkins guiding catheter generates
strong backup like an extra backup catheter, but has a tip
that is oriented slightly in the medial direction, which
makes it more likely to advance toward the LAD when
pushed forward (Fig.1.17). Even if there is plaque at the
ostium of the left main trunk (LMT), it is easier to disengage a guiding catheter of this type while keeping it
coaxial with the LMT.For these reasons, I choose a shorttipped Judkins-type guiding catheter when performing
PCI for CTO of the LMT or LAD (Fig.1.18).
On the other hand, a short-tipped Judkins catheter is inappropriate for PCI when the CTO is in the LCX because its tip
is oriented slightly toward the LAD, i.e., contralateral to the
LCX.The guidewire has to be redirected toward the LCX,
so it becomes difcult to handle, and this guiding catheter
only provides poor backup for the LCX.In contrast, an extra
backup type of guiding catheter with an appropriate curve
size will have the tip directed toward the LCX when it is
engaged normally, and the tip will be directed further toward
the LCX when it is pulled back slightly. Accordingly, I think
that the extra backup guiding catheter is optimal when performing PCI for CTO of the LCX (Fig.1.18).
To perform PCI for CTO of the LCA, I formerly used
AL-type guiding catheters, but I rarely do so now. The main
reason I no longer use AL-type catheters for LCA lesions is
that this type of catheter is much more likely to cause coronary artery injury when it is removed from the LMT compared with the RCA.Over the years, techniques using Judkins
or EBU guiding catheters without stressful engagement have
become the mainstay of PCI for the LCA.These techniques
include use of a guiding catheter with the tip shaped by heating to ensure coaxiality with the LMT, advancing the guiding catheter over a guidewire initially introduced into the
Fig. 1.15 Points to consider when removing a guiding catheter at the
end of the procedure. You should never simply pull back on the catheter
because removing a catheter in this way is likely to cause ostial injury
(a). Instead, you should push the catheter in deeper while rotating it
counterclockwise to disengage the tip. After the catheter tip has come
out of the RCA ostium, you should slowly withdraw the entire catheter
until the tip reaches the level of the aorta (b). If this method of disengagement fails, you should slowly pull the catheter back while rotating
it anticlockwise to disengage the tip. With the latter method, the tip of
the catheter will go directly up to the level of the aorta, and it should be
maintained at that level
target coronary artery (guidewire cannulation technique),
and leaving the guidewire in place as a buddy wire (buddy
wire technique).
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When the guiding catheter is advanced
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LAD
1 Mitsudo’s PCI Techniques forCTO
LCX
JL Short tip
SL-4
Fig. 1.16 Guiding catheters for the LCA.I only use the regular Judkins
left (JL) guiding catheter (b) in exceptional circumstances. This type of
guiding catheter has a rst curve that is too long, so its tip is often oriented toward the roof of the LMT, potentially causing LMT injury and
only providing poor backup. In contrast, the SL type of catheter with a
short rst curve (a) is rarely directed toward the roof of the LMT and is
more likely to become coaxial with this segment of the LCA.The extra
backup type of catheter is also more likely to become coaxial with the
LMT and provide good backup
EBU-4
Judkins Left
(JL-4)
LAD
LCX
Fig. 1.17 Short-tipped (ST) Judkins left and extra backup guiding
catheters for the LAD (especially the LAD ostium). (1) ST Judkins left
catheter: If the tip is not engaged deeply, it may be difcult for the
catheter to track the LAD (a). Even in such circumstances, the curve of
the tip sends the catheter toward the LAD when the catheter is advanced
(b) and makes subsequent manipulation of a guidewire easier. (2) Extra
backup catheter: If it is difcult to direct the catheter toward the LAD
(c), further advancement of the catheter may result in it entering the
LCX (d) rather than the LAD
LCX
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When the catheter is pulled back
1.3 Guiding Catheter
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Fig. 1.18 Various guiding
catheters for the LCX. (1) ST
Judkins left catheter: This type of
guiding catheter can sometimes
be directed toward the LCX after
it has been pulled back
considerably. Once the catheter
has been directed toward the
LCX, its second curve becomes
nearly parallel with the long axis
of the aorta, which means that the
catheter cannot provide strong
backup while remaining coaxial
with the LCX. (2) Extra backup
catheter: A catheter of this type is
easily directed toward the LCX
when it is pulled back. Since its
tip and shaft become nearly
perpendicular to the long axis of
the aorta, it is likely to provide
good backup while remaining
concentric with the LCX. (3)
Amplatz left catheter: The tip of
this type of catheter is likely to
become coaxial with the
LCX.However, in the position
shown in e, this catheter cannot
provide good coaxial backup
with the LCX, and it has to be
pulled back to gain coaxiality
with the LCX.When this catheter
is pulled back, control of its tip
may be lost, leading to stress on
the base of the LMT, or it may
become deeply engaged or
disengaged
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LAD
LCX
LAD
LCX
LAD
1.3.1.4 Size oftheCatheter Tip Curve
Interventionalists in the USA and Europe often use 3.5-cm
extra backup guiding catheters to perform PCI for CTO of the
LCA in male patients. For a Japanese male patient, I think a
catheter of this size is too small, and I use a 4.0-cm guiding
catheter. It is true that you can easily engage a 3.5- cm guiding
catheter in the LCA, but it is hard to achieve the principal purpose of providing strong backup with a catheter of this size. For
example, I usually select a 4.0-cm SL guiding catheter, which
provides stronger backup than a 3.5-cm Launcher extra backup
catheter. If a 4.0-cm extra backup guiding catheter is too large
(though this only happens infrequently, as with the SL type), it
should be changed to a 3.5- cm catheter. In principle, I choose a
guiding catheter with a curve that is one size smaller for female
patients. However, a guiding catheter of the size recommended
for male patients may often be optimal for female patients,
depending on the size of the aortic sinus of Valsalva.
You can successfully engage the guiding catheters listed
in Table 1.2 in the LCA in 99% of patients, but will fail to
achieve engagement in the remaining 1%. If failure occurs, I
recommend inserting a copper wire into the tip of the guiding
catheter for a distance of about 10cm, reshaping the catheter tip and softening it by heating, and then immediately
immersing the tip in cold water to maintain the new shape
(Fig. 1.19). After removing the copper wire, you should
engage the guiding catheter in the LCA ostium as soon as
possible before the catheter undergoes further deformation
due to overheating.
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Table 1.2 Guiding catheters for CTOs in various coronary artery segments
Male patients Female patients
RCA First choice BriteTip AL 1 ST Launcher SAL 1
Variation BriteTip AL 1–AL 3Launcher SAL 1 BriteTip AL 1–AL 3
Rare JR (shepherd crook), AR (downward orientation)
LCA LM, LAD First choice Launcher SL 4 Launcher SL 3.5
Variation Launcher SL 3.5, 4.5, 5.0 Launcher ST 4.0–5.0
LCX First choice Launcher EBU 4.0 Launcher EBU 3.5
Variation Launcher EBU 4.5 Launcher EBU 3.5 Launcher EBU 4.0, 4.5
Rare AL
(or hairdryer)
Copper
wire
Heater
Fig. 1.19 Procedure for reshaping a guiding catheter (ST Judkins). (a)
Cut a 15-cm-long piece of thick copper wire (desirably 0.8 to 1.0mm in
diameter), and sterilize it. (b) Insert the copper wire into the tip of the
guiding catheter for a distance of about 10 cm, and curve the tip to
obtain the desired shape. Evenly heat the tip with a heater (or a haird-
1.3.2 Anchoring Technique
ryer) to soften it, and immediately immerse the tip in water to cool it,
and ensure that it retains the new shape. After the catheter has been
cooled, remove the copper wire, and promptly engage the guiding catheter in the target coronary artery
optimal size with reference to the branch diameter sometimes fails to have an anchoring effect when inated at too
When performing PCI for CTO of the RCA, AL-type guid-
high pressure.
ing catheters of the appropriate size can provide good
backup. However, it is sometimes necessary to continue PCI
with a guiding catheter that has a curve which is too small for
the sinus of Valsalva. This means that the guiding catheter
cannot provide sufcient backup or ensure stable guidewire
manipulation (Fig.1.20a). In this situation, prompt use of the
anchoring (anchor balloon) technique is recommended if a
suitable side branch is available (Fig.1.20b).
1.3.2.2 If No Side Branch Is Available
forAnchoring
If there is no side branch available for anchoring, the guiding catheter should be changed to a larger AL-type catheter
to obtain sufcient backup from the contralateral wall of the
sinus of Valsalva.
A side branch that is located too close to the target coronary artery ostium cannot be used for anchoring to increase
1.3.2.1 Size andInation Pressure
oftheAnchoring Balloon
The anchoring balloon should desirably be one size larger
than the diameter of the side branch used for anchoring and
should be short (10 to 15mm). To perform anchoring, the
balloon should be inated at a low pressure such as 4atm.
If the side branch for anchoring is tapered, a long balloon
will slip out when it is inated. Even if the balloon is the
optimal size, it will not have an anchoring effect or will
slip out if it is inated at a high pressure. If the side branch
contains calcied plaque, a balloon that seems to be of the
backup. In fact, anchoring the catheter from such a side
branch may rather decrease backup because the shaft of the
anchoring balloon will not become coaxial with the coronary artery (Fig.1.20b). However, even a side branch located
close to the coronary artery ostium can be used for anchoring
with another purpose in mind, i.e., to prevent the guiding
catheter from slipping out of the ostium.
If the distance between the CTO and the coronary artery
ostium is adequate to permit deep engagement of a guiding
catheter, a child catheter such as the GuideLiner® can also
be used to provide good backup.
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Fig. 1.20 Anchoring technique. (a) After starting PCI for a CTO of the
RCA, loss of coaxiality between the guiding catheter and the RCA
ostium occurred when the guidewire was advanced slightly. (b)
Anchoring by using the conus branch maintained the guiding catheter
coaxial to the RCA ostium and considerably improved guidewire
manipulability. (c) Anchoring by using a side branch near the RCA
ostium resulted in loss of coaxiality between the guiding catheter and
the ostium. Exchanging the guiding catheter allowed coaxiality to be
regained, but backup was somewhat impaired
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Column 1 Guidewire Cannulation and Buddy Wire Techniques
1 Mitsudo’s PCI Techniques forCTO
If incomplete engagement of a guiding catheter results in laminar ow imaging of the target coronary artery (Fig.1.21
a–d), it is difcult to obtain good images without taking additional measures. To achieve complete engagement of the
guiding catheter for optimal imaging and backup in this situation, I sometimes introduce a guidewire rst and advance
the guiding catheter over the guidewire. When advancing the guiding catheter, I do not recommend forcibly rotating or
pushing it forward. Instead, to-and-fro movement should be repeated in the appropriate direction while slightly rotating
the catheter. If you still fail to achieve engagement of the guiding catheter, I recommend using another guidewire (plus a
microcatheter) as a buddy wire. By this technique, you can advance the guiding catheter slightly while keeping it coaxial
with the coronary artery ostium and can achieve engagement without generating much stress.
These techniques are also useful for engaging a guiding catheter with no side holes in a stenotic ostium so that it is
slightly out of the wedged position.
a
b
Fig. 1.21 (a, b) Incomplete engagement of a guiding cath-
eter results in laminar ow imaging of the target coronary
artery. (c, d) After introducing a guidewire, the guiding cath-
eter could be engaged (c). In this case, deeper engagement of
the guiding catheter to ensure enough backup would result in
laminar ow imaging again. Therefore, a microcatheter was
advanced, and tip injection was performed in order to assess
the anatomy of the target vessel (d)
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1.3 Guiding Catheter
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Column 2 Handling Coronary Arteries with Anomalous Origin
To engage a guiding catheter in a coronary artery with anomalous origin, you often must improvise when selecting the catheter and/or modify the engagement procedure.
[High take-off RCA]
Unlike a normal RCA, an RCA originating from the ascending aorta often arises in the left anterior position and
runs downward. To achieve successful engagement in patients with such a “high take-off” RCA, you should choose an
AL-type guiding catheter with a relatively large second curve and should direct its tip downward. One way to direct
the tip downward is to seek the RCA ostium with the tip initially oriented down and to the left anteriorly (Fig.1.22a).
Another way is to pull up the catheter with its tip bent upward. When the tip is trapped by a dimple, upward movement
should be continued slowly while keeping the tip at the dimple until the tip becomes oriented downward and coaxial
with the RCA ostium. Then engagement of the catheter will be accomplished by slightly advancing the tip into the
ostium (Fig.1.22b).
Fig. 1.22 High take-off RCA
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1 Mitsudo’s PCI Techniques forCTO
[RCA originating from the left sinus of Valsalva]
To achieve engagement of a guiding catheter when the RCA originates from the left sinus of Valsalva requires complicated
maneuvers. The RCA usually runs anteriorly to the right for a short distance from its ostium (normally located to the right and
anterior to the aorta [sinus of Valsalva]) and then runs caudally. As is clearly seen on CT scans, if the tip of a guiding catheter
is coaxial with the RCA ostium, the shaft of the catheter is almost perpendicular to the contralateral aortic wall (Fig.1.23a). If
the RCA originates from the left sinus of Valsalva, it runs anteriorly along the aorta from its origin. Therefore, if the RCA has
such an anomalous origin, it is difcult to maintain the tip of a standard guiding catheter coaxial with the proximal part of the
target vessel. Although a guiding catheter can be engaged in an anomalous RCA like this and the tip can be maintained coaxial
to the ostium, engagement will not be deep enough to obtain good images or to provide strong backup (Fig.1.23b).
An Amplatz left-type guiding catheter with a customized curved tip or a three-dimensional (3D) guiding catheter can be
engaged at a relatively deep level and can provide enough backup for standard PCI, but it is often not sufcient for successfully crossing a CTO (Fig.1.23c).
If a side branch is available for anchoring, the anchoring technique is most effective for helping to accomplish
engagement of the guiding catheter. If there is no suitable side branch, using a child catheter such as the GuideLiner is
somewhat effective (Fig.1.23d).
a
b-1 b-2
Fig. 1.23 RCA originating from the left sinus of
Valsalva. (a) RCA with a normal origin. The shaft of the
guiding catheter is perpendicular to the contralateral aortic wall, providing good backup. (b) RCA originating
from the left sinus of Valsalva (1). A guiding catheter
engaged in the ostium does not generate good backup
(b-1), and engagement becomes less deep if the shaft is
made perpendicular to the contralateral aortic wall (b-2).
(c) RCA originating from the left sinus of Valsalva (2). A
different guiding catheter may provide stronger backup,
but this may still not be enough for treating a CTO. (d)
The anchoring technique or use of a child catheter can be
somewhat effective for helping to achieve adequate
engagement of the guiding catheter
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