*2.3.3 Choice for guide catheter tip curve, shape and length for PCI depends on several factors*

The access approach: radial right, left or femoral. Technically, most of femoral guide catheters could be used in radial approach and vice versa. However, some guide catheters are originally designed for radial approach (i.e. XB) and would be more effective if it is used for the same purpose especially nonexperience operators and in challenging interventions. A big advantage of radial approach is the availability of multiple guide catheter that can be used as a single catheter to perform diagnostic and intervention using same catheter for left and right with very good support and without the need to exchange. Some of these guide catheters are: EBU, Kimny, Q-Curve, Multi-Aortic Curve MAC and even Amplatz left. Manipulating and adjusting the guide bend with 0.035″ wire might be required to achieve that (Wire assisted guide engagement technique). Using the guide wire can make any left contralateral support catheter (EBU, XB, Kimny, Voda, Q-Curve, FCL, MAC, CLS, Kiesz left, Amplatz left) a single catheter for both left and right but this requires caution and experience to avoid advancing the 0.035″ wire inside the coronary (**Figure 3**). Left radial approach is similar to femoral approach in regard to guide catheter choice. Anatomical factors:

The diagnostic catheter used to perform diagnostic angiogram is one of the most important factors. The diagnostic angiogram procedure is very important in general in deciding the choice for interventional guide catheter as it provides information about the difficulty of vessel engagement, vessel take off, position of the heart in the chest, ascending aortic length, width and orientation in chest, length and degree

Judkins Left (least support) Catheter with two bends the sort bend does

Ikari Left Radial guide: can be used for both left and

Kimny Similar to Ikari but more support

Contralateral Support Catheters (EBU, XB, Voda left, CLS, Q Curve, Kiesz left)

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

Amplatz Left, SAL (Best

*Classification of left coronary system guide catheters by level of support.*

support)

**Table 9.**

**217**

not provide much support. Can have some advantage for ostial and proximal left main lesions where deep engagement is

right interventions as a single catheter technique (Useful in STEMI). Better support that JL but for the same double

Very good support from contralateral aortic wall or sinus of Valsalva. EBU and Q curve can be used as a single catheter for left and right (STEMI cases). A workhorse

Voda left is a good support catheter for

Best support guide catheter. Deep engagement. Very useful for complex PCI

and CTO interventions

guide catheter

LCX interventions

contraindicated

curve reason

**Figure 3.** *Changing catheter tip shape with wire assist.*

of required support of the guide catheter. In femoral and radial approaches using pre-shaped diagnostic catheters, guide catheter length is usually 0.5 shorter than the diagnostic catheter used. This rule does not apply for radial approach when a single diagnostic catheter is used. In this case, operator makes the choice based on the diagnostic catheter used and the other factors.

The vessel involved; left anterior descending (LAD) or left circumflex (LCX), or right coronary artery (RCA), the location of takeoff of the vessel, presence of anomalous coronary and the shape of coronary or graft takeoff.

Lesion specific factors: the location of the lesion (ostial or not), the difficulty of the lesion and the need for support (tortuous, calcified coronary) (**Tables 9** and **10**), setting of intervention CTO vs. acute vs. elective case.

For left system: shorter guides will selectively engage LAD and longer guides will electively engage and support LCX like Voda left (VL) and Amplatz left (AL).

## *2.3.4 Special cases for choosing appropriate guide catheters*

*Left coronary system*: there are large range of guide catheters GC especially for left system catheters and all of them can be used in all different left system variable anatomies. XB, EBU, CLS, VL, SAL, MAC, Q-wave and AL catheters can provide good contralateral aortic or leaflet support especially during radial approach. JL/FL guide catheter are the old typical GC used in femoral approach. It provides minimal support from femoral approach. However, during radial approach, support of this GC can varies depending on the brachiocephalic and aortic anatomy. There are variable take offs and length of the left main. Superior take off would require longer GC to engage and at the same time achieve good support from aortic leaflet with or without contralateral aortic support. Horizontal take off could be engaged from the top by JL/FL GCs or by contralateral support GC. Short left main and separate ostia of LAD/LCX poses more challenge. Longer GC could engage either LAD or LCX selectively which could be a significant advantage when the target lesion is beyond the ostium. This provides much strong support for intervention but might occludes the other vessel and induces ischemia. This challenge is sometime unavoidable and thus could be managed by careful intermittent engagement and disengagement as needed during intervention. On the other hand, shorter GCs are needed for ostial target lesions.

For ostial left main interventions, a guide with side holes and easy way to disengage is preferred. JL/FL are good guide catheters for that. Still, contralateral

**Table 9.** *Classification of left coronary system guide catheters by level of support.*

of required support of the guide catheter. In femoral and radial approaches using pre-shaped diagnostic catheters, guide catheter length is usually 0.5 shorter than the diagnostic catheter used. This rule does not apply for radial approach when a single diagnostic catheter is used. In this case, operator makes the choice based on the

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

right coronary artery (RCA), the location of takeoff of the vessel, presence of

electively engage and support LCX like Voda left (VL) and Amplatz left (AL).

For ostial left main interventions, a guide with side holes and easy way to disengage is preferred. JL/FL are good guide catheters for that. Still, contralateral

anomalous coronary and the shape of coronary or graft takeoff.

The vessel involved; left anterior descending (LAD) or left circumflex (LCX), or

Lesion specific factors: the location of the lesion (ostial or not), the difficulty of the lesion and the need for support (tortuous, calcified coronary) (**Tables 9** and **10**),

For left system: shorter guides will selectively engage LAD and longer guides will

*Left coronary system*: there are large range of guide catheters GC especially for left system catheters and all of them can be used in all different left system variable anatomies. XB, EBU, CLS, VL, SAL, MAC, Q-wave and AL catheters can provide good contralateral aortic or leaflet support especially during radial approach. JL/FL guide catheter are the old typical GC used in femoral approach. It provides minimal support from femoral approach. However, during radial approach, support of this GC can varies depending on the brachiocephalic and aortic anatomy. There are variable take offs and length of the left main. Superior take off would require longer GC to engage and at the same time achieve good support from aortic leaflet with or without contralateral aortic support. Horizontal take off could be engaged from the top by JL/FL GCs or by contralateral support GC. Short left main and separate ostia of LAD/LCX poses more challenge. Longer GC could engage either LAD or LCX selectively which could be a significant advantage when the target lesion is beyond the ostium. This provides much strong support for intervention but might occludes the other vessel and induces ischemia. This challenge is sometime unavoidable and thus could be managed by careful intermittent engagement and disengagement as needed during intervention. On the other hand, shorter GCs are needed for ostial

diagnostic catheter used and the other factors.

*Changing catheter tip shape with wire assist.*

**Figure 3.**

setting of intervention CTO vs. acute vs. elective case.

*2.3.4 Special cases for choosing appropriate guide catheters*

target lesions.

**216**

aortic support GC can be used especially when additional interventions with sup-

*Classification of right coronary system guide catheters by level of support.*

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

Amplatz Left, (Best support) Best support guide catheter. Deep engagement.

Very useful for complex PCI and CTO interventions A very good support guide catheter for all venous graft interventions and for the same reason, it is good for abnormal take off of the RCA (anterior, superior, and posterior)

*RCA system:* because of the variable origin and takeoff of the RCA (posterior, anterior, superior anterior origins, inferior, horizontal, superior, Shepherd's Crook take offs), contralateral support guides for RCA interventions are less available, but some of the left guides can be used for the right interventions with aortic contralateral wall support like EBU, Voda, SAL, Q-Curve, MAC, and AL. Some companies have more specific right guide catheter with contralateral aortic wall support (Voda

Contralateral support is very important for RCA interventions that needs significant support. However, workhorse guide catheters (JR/FR/IMA/3RDC/AR) are still mostly used due to their availability and operators' comfort level using them especially in challenging RCA take offs. Coaxial engagement and good support are two qualities for good interventions that are difficult to obtain at the same time in abnormal RCA take off using especially using workhorse GCs. For example: inferior take off engagement with multipurpose GC would provide good engagement but minimal support. Superior and Shepherd's Crook take off are one of the most challenging cases for any operator. Special radial designed GCs (KR superior, Voda right, RCA Shepher's Crook RC4SC, Ikari right) also can be very helpful. Posterior origin of the RCA can be reached with WRP, multipurpose AR and AL GCs. Anterior origin of the RCA would require long GC such as AL. Using RAO projections

For the most common coronary anomaly (LCX origin from RCA): multipurpose GC and JR short tip are good options. However, due to poor support, aforementioned contralateral aortic GCs can provide significant support with deep engage-

*Grafts*: internal thoracic artery or internal mammillary artery IMA has special diagnostic catheters with similar guide catheters like regular IMA tip and LIMA VB-1 that can be used. JR, 3RDC, Cobra and LCB guides can be used too and all

Thrombotic lesions are common findings in ACS especially STEMIs and venous grafts lesions. There are multiple available catheters approved for cardiac vessels

Venous grafts can be engaged and intervene on using multiple catheters depending on their take off: JR, AL, IMA, special RCB, LCB right and left coronary bypass catheters, MPA, Hockey stick or even JL. Some operators use catheters used to engage abdominal aorta branches like Cobra, Renal catheters RC, Contralateral, MIK, HK1.0 or SHK. Amplatz left is a workhorse GC that can be used in all venous grafts and almost any types of origins or take offs while providing best support. RIMA: free RIMA is imaged and intervene on similar to venous grafts depending on its origin from the aorta. Pedicle RIMA can be reached by right radial approach or femoral approach. JR, Barbeau or special RIMA guide catheter can be helpful in

can be very helpful to engage posterior and anterior origin.

depends on the LIMA take off left subclavian.

ment that can cause pressure dampening and decrease coronary flow.

port is required.

**Table 10.**

with right curve).

femoral approach.

**219**

**Table 10.**

Judkins Right (least support) A workhorse guide catheter. Very useful for all

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

Multipurpose Requires significant manipulation and use f

Ikari Left, Ikari Right Radial guide: can be used for both left and right

Amplatz Right, KR (Kiesz Right), Hockey stick

Contralateral Support Catheters (EBU, XB, Voda, CLS, Q-Curve MAC)

**218**

types of take offs Very useful for engaging all venous grafts and head vessels IMA guide catheter is similar with more acute distal bend

A little better support than JR but still passive support with no contralateral support Also can be used for engaging venous grafts

wire to support it. Very helpful in most downward pointing vessels like RCA and right venous grafts and anomalous LCX

interventions as a single catheter technique (Useful in STEMI). Provide contralateral and better support for right interventions than left

Very good support from contralateral aortic wall or sinus of Valsalva EBU, Q curve and MAC (Multi-Aortic Curve) guide catheter can be used as a single catheter for left and right using radial approach (STEMI cases). Another advantage of radial approach to make these guides workhorse guide catheters Voda right is a specific for RCA

*Classification of right coronary system guide catheters by level of support.*

aortic support GC can be used especially when additional interventions with support is required.

*RCA system:* because of the variable origin and takeoff of the RCA (posterior, anterior, superior anterior origins, inferior, horizontal, superior, Shepherd's Crook take offs), contralateral support guides for RCA interventions are less available, but some of the left guides can be used for the right interventions with aortic contralateral wall support like EBU, Voda, SAL, Q-Curve, MAC, and AL. Some companies have more specific right guide catheter with contralateral aortic wall support (Voda with right curve).

Contralateral support is very important for RCA interventions that needs significant support. However, workhorse guide catheters (JR/FR/IMA/3RDC/AR) are still mostly used due to their availability and operators' comfort level using them especially in challenging RCA take offs. Coaxial engagement and good support are two qualities for good interventions that are difficult to obtain at the same time in abnormal RCA take off using especially using workhorse GCs. For example: inferior take off engagement with multipurpose GC would provide good engagement but minimal support. Superior and Shepherd's Crook take off are one of the most challenging cases for any operator. Special radial designed GCs (KR superior, Voda right, RCA Shepher's Crook RC4SC, Ikari right) also can be very helpful. Posterior origin of the RCA can be reached with WRP, multipurpose AR and AL GCs. Anterior origin of the RCA would require long GC such as AL. Using RAO projections can be very helpful to engage posterior and anterior origin.

For the most common coronary anomaly (LCX origin from RCA): multipurpose GC and JR short tip are good options. However, due to poor support, aforementioned contralateral aortic GCs can provide significant support with deep engagement that can cause pressure dampening and decrease coronary flow.

*Grafts*: internal thoracic artery or internal mammillary artery IMA has special diagnostic catheters with similar guide catheters like regular IMA tip and LIMA VB-1 that can be used. JR, 3RDC, Cobra and LCB guides can be used too and all depends on the LIMA take off left subclavian.

Venous grafts can be engaged and intervene on using multiple catheters depending on their take off: JR, AL, IMA, special RCB, LCB right and left coronary bypass catheters, MPA, Hockey stick or even JL. Some operators use catheters used to engage abdominal aorta branches like Cobra, Renal catheters RC, Contralateral, MIK, HK1.0 or SHK. Amplatz left is a workhorse GC that can be used in all venous grafts and almost any types of origins or take offs while providing best support.

RIMA: free RIMA is imaged and intervene on similar to venous grafts depending on its origin from the aorta. Pedicle RIMA can be reached by right radial approach or femoral approach. JR, Barbeau or special RIMA guide catheter can be helpful in femoral approach.

Thrombotic lesions are common findings in ACS especially STEMIs and venous grafts lesions. There are multiple available catheters approved for cardiac vessels

interventions (**Table 11**). They share the same principle of mechanical aspiration embolectomy that depends on manual or machine assisted aspiration of the clot. Multiple passes might be required for some cases. No blood return while aspirating is a sign of either poor flow triggered by clot occluding the catheter or suctioning against the vessel wall. When no blood return is seen, the catheter should be withdrawn till blood return is seen. If blood return still not seen, the catheter should be removed out of the body and examined for clot at the tip. It is very important to keep negative pressure while withdrawing the catheter out of the GC followed by bleed back of the GC to remove any potential clot left within the GC.

Aspiration thrombectomy can aspirate the clots from the coronaries and displace it to systemic circulation. The data of using aspiration embolectomy is controversial. Most recent guidelines recommend against their routine use due to increased risk of embolic strokes and no clinical outcome benefit. However, some cases with significant thrombosis cannot be resolved without their use.

Coronary micro-catheters are small catheters compatible with 0.014″ coronary wires. There is a wide spectrum of micro-catheters with different designs (**Table 12**). They provide operators with significant ability to provide wire exchanges, crossing difficult lesions, assist wiring difficult angulated lesions (**Table 13**) and many other technical advantages especially in CTO interventions.

Upsizing or exchanging GC to provide more support during procedure is challenging after crossing a difficult lesion or any case where guide wire position is critical. The risk of losing guide wire position while loading the new GC is high. Long guide wire or adding extension wire is first step. More support with additional buddy wire and/or using micro catheter inside the new GC could be helpful.


**2.4 Choosing the appropriate guide wire**

Corsair Corsair Pro

Volcano Valet 135 cm,

**Manufacturer Catheter name Length Distal shaft outer**

Finecross MG 130 cm,

Renegade 18 105 cm,

Mamba Flex 135 cm,

Minnie 90 cm,

Turnpike 135 cm,

Turnpike LP 135 cm,

Turnpike Spiral 135 cm,

Caravel 135 cm,

Cordis Transit 135 cm 2.5

MicroCross 14 es

135 cm, 150 cm

130 cm

150 cm

150 cm

114 cm, 135 cm

Mamba 135 cm 2.3

150 cm

Prowler 150 cm 1.9

135 cm, 150 cm

150 cm

150 cm

150 cm

135 cm, 150 cm

150 cm

150 cm

Asahi Tornus 135 cm 2.1 and 2.6 To advance it,

Turnpike Gold 135 cm 3.2

155 cm 1.6

Teleport Teleport Control

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

Terumo Progreat 110 cm,

Spectranetics Quick Cross 135 cm,

Raxwood MicroCross 14

CSI

Boston Scientific

Vascular solutions

**Table 12.**

**221**

*Coronary micro catheters.*

cardiovascular systems

**diameter (French)**

2.0 Proximal shaft 2.6 2.1 Proximal shaft 2.7

2.0

2.1

2.2

2.6

2.2

3.1

2.6

1.9

**Notes**

Advanced both by clock and counterclockwise rotation

coils and 0.018 wires

support to cross any lesion

coils and 0.018 wires

counterclockwise rotation

1.8 Shapeable distal tip

2.4 and 2.7 Used for coiling with large

1.8 Very small, not much

2.5 Used for coiling with large

wires especially high risk and CTO operators.

There are large number of guide wires from different companies with different characteristics. Operator should be comfortable and familiar with design, characteristics, advantages, and disadvantages of at least workhorse wires and special
