Hi there. I'm Tara Jones. I'm one of the interventional cardiologists at the University of Utah. And I developed this presentation with the assistance of our calf lab nurse educator here at the U, Tiffany Espinosa. And we're going to talk about common catheters for diagnostic coronary angiography. Neither one of us have any particular disclosures. And today we're just going to briefly review common catheters used for diagnostic coronary angiography and discuss the pros and cons of various catheters and approaches. So first of all, just a little bit of a slide to show the difference between diagnostic and guiding catheters. I know there's a separate lecture on guiding catheters, but really, you know, the catheters are quite different. The outer diameter of a five, six French diagnostic and guide catheter are the same. However, diagnostic catheters have a thicker shaft and a smaller internal diameter. They also have a tapered tip and are softer, so less reinforced. This is in contrast to guiding catheters that have a thinner shaft while maintaining the same outer diameter to allow for a larger internal diameter to perform coronary intervention. The tips of these catheters are non-tapered and they are stiffer catheters, more reinforced. On the bottom of this slide is just sort of a picture or cartoon of a guiding catheter makeup and there's an outer jacket. And inside there's a stainless steel mesh work in between that and the inner coating, which make the catheter more stiff. So more likely to cause coronary injury, although can occur with diagnostic catheters as well. So moving on to diagnostic catheters, there are several different types of diagnostic catheters. There are pre-shaped catheters for the left coronary artery, the right coronary artery and bypass angiography. These types of catheters can be used either from the femoral or radial arterial access sites. Common left coronary catheters are the Judkin's left and the Amplot's left. These are funny names and they're for a catheter, but they're really actually named after the individuals who invented the shape of this catheters of Melvin Judkin's and Amplot's. Similarly, there are right coronary catheters, most commonly the Judkin's right, the Amplot's right, and something called a 3DRCE, which you may also hear referred to as a no-torque. And then common bypass graft catheters are the IMA, which stands for internal amyloid artery. So you use that to engage the LEMA or the REMA graft. Left coronary bypass and right coronary bypass are LCB and RCB. There are also universal catheters designed to engage both the left coronary artery and the right coronary artery from the radial approach. These catheters are really only used from the radial. It's very uncommon for them to be used from a femoral access site. And the names of these catheters are the Jackie, the Tiger, and less commonly the Sarah. So to start off, talk about the most commonly used catheters that are pre-shaped, and that's the Judkin's type coronary catheters. They're a pre-shaped double curve. The JL stands for left coronary artery and JR stands for right coronary artery. And the number that comes behind JL or JR is really the length of the segment between the primary and secondary curve. So pictured here on the right of the slide is a JL catheter and a JR catheter. And the length between this primary curve and the secondary curve is in centimeters and it's essentially the length of that segment. So JL35 is three and a half centimeters, four is a four centimeter, and so on. The size selected is really based on the length and width of the ascending aorta and your access site. So for example, a JL35 is breaths from the right radial artery while a JL4 may be best from the left radial or femoral approach. Additionally, it's based on the size of the patient. So a small person with a small aorta may end up needing a JL35 from the groin or the left radial, whereas in a large person or an individual with a dilated ascending aorta, you may need even a five or a six centimeter catheter to successfully engage the coronary artery. So this is a cartoon of how these catheters engage the right and the left coronary artery from the groin. A JL4 catheter fits most adults pretty easily. And the catheter is designed to sort of bounce off the contralateral wall of the aorta and then align parallel with the left coronary ostea. And it's pretty simple to engage usually from the groin with the JL catheter. A JL4 catheter requires a little bit more maneuvering to engage the right coronary artery, but is still quite easy for an experienced operator. The right coronary artery, essentially the JL catheter requires just a little bit more manipulation, but it's either advanced right down into the right coronary cusp of the aortic valve and then rotated clockwise and pulled back to sort of bounce up and engage the coronary, or maybe a little less commonly, they'll advance the catheter to right above the valve and then just rotate, but not sort of pull back. And this catheter often descends approximately with torquing from the groin. Moving on to the amplot-type coronary catheters. These are a pre-shaped curve with the tip extending perpendicular to the curve. So again, AL is for amplot's left, AR is for amplot's right. And the catheter sizes, so one, two, or three for the left or one or two for the right indicates the diameter of the tip curve. So one centimeter is an AL1 or AR1, two centimeters is an AL2 or an AR2, et cetera. And you select the size of this catheter based on the width of the ascending aorta and the coronary osteo height. So the way that these catheters engage the coronary arteries is that the tip is advanced into the coronary cusp, and then further advancement kind of moves the tip upward towards the left or the right coronary artery. You'll often hear operators say, well, I'm just going to amplot's it up, even if it's not with an amplot's catheter. And that's really just a maneuver that means you're going to sort of bounce it off, bounce a catheter off the aortic valve and then up into the coronary osteum. Engagement with these catheters is also pretty simple for an experienced operator, but it can result in unwanted deep cannulation of either coronary artery. And for that reason, the incidence of dissection or vessel injury is a little bit higher with amplot's catheters and with Judkin's catheters, although still relatively rare. Moving on to universal radial catheters. These again are designed for coronary engagement from the radial approach. It can be used to engage both the left and the right coronary artery. These are the two of the commonly used universal radial catheters that you see in various labs. The TrumoTiger and the TrumoJackie are probably the most common. The Serra is a little bit less common. The advantages really to a universal radial catheter is that you have fewer catheter exchanges and this results in reduced potential for radial artery spasm, as well as decreased procedure time. But it can be challenging in sort of an anatomic variance to engage the coronaries with these universal catheters. This is a sort of a picture or a cartoon of how the universal catheters, this is the Tiger, can be used to engage both the right and the left coronary artery. They're designed again to be used from the radial approach and it worked pretty well, although it can be challenging in certain anatomic variance if the ostea come off a little bit of an anterior spot or if you have an anomalous right coronary artery or something, it can be challenging with the universal catheters. I just wanted to say a little bit about pigtail catheters. These are not used to perform coronary angiography, but it's the most common and safest choice for ventriculography and aortography. Pigtail catheters are a pre-shaped catheter that make kind of a circle at the tip and then there's anywhere from sort of six to 12 side holes along the length of the catheter and the shaft here. And it's used to perform angiography of larger structures like the left ventricle, right ventricle, or aorta. They come in straight and angled. The one on the side here is an angled pigtail, straight just means that this curve right here is not present. These are most often used for hemodynamic studies nowadays, but some operators will still use them for ventriculograms or aortograms in different clinical circumstances. You know, ventriculography was once considered an integral part of every cath procedure, but has been reconsidered sort of in modern day because there's really high quality echo now for assessment of LV function and wall motion. And then there are advanced imaging techniques for a better assessment of the ascending aorta. However, if a ventricular gram is going to be performed, an end hole catheter such as the JR4 is really kind of considered a no-no. This is because end hole catheters can cause serious harm with poor catheter positioning. If the end hole catheter is abutted against the wall of the ventricle, a forceful injection can cause something as catastrophic as LV perforation. So if a ventriculogram or an aortogram is going to be performed, it really should probably be done with a pigtail catheter. There is a separate lecture on hemodynamics that will probably go into this in a little bit more detail, but I just wanted to mention it briefly here. For pressure damping and ventricularization, it's important to remember when performing any sort of angiogram, whether it be a diagnostic angiogram or an intervention, because it's indicative of something wrong with the position of your catheter. The next thing is the picture here on the top, and it really is a sort of drop in pressure and a decreased pronouncement of the waveform on your hemodynamic monitoring. This can occur when the outer diameter of the catheter is as large or larger than the ostium, so somebody has osteal disease, or if a catheter tip is pressed up against a vessel wall, be it the aorta or if it's roofed kind of up against the wall of the coronary, you can't see pressure damping as well. Ventricularization is kind of a similar concept in that it can occur when the catheter tip is advanced sort of into an osteostenosis, and really when the outer diameter of the coronary ostea is only slightly larger than or the same size as the catheter. And what this looks like is really, you get these sort of deep diastolic declines, kind of looking like more of a left ventricular pressure than an aortic pressure. This is something that cath lab monitors and nurses should really watch for when operators are engaging or working in the coronary arteries, because it can be indicative of a potentially harmful catheter position. So to conclude our lecture with diagnostic catheters is that, you know, the Judkin's catheters are the most commonly used catheters from the femoral approach. Amplat's catheters can be used and can be useful in certain anatomic variants, but careful engagement is necessary to avoid coronary injury. Universal radial catheters have advantages, though coronary angiography via the radial approach can be performed with Judkin's or Amplat's catheters as well. And finally, aortic size and anatomic origin of the coronary ostea as well as access approach determines the choice of the catheter that you're going to use. So hopefully this was helpful. Thank you for your attention and please check out the other lectures in this series. Thank you.

Dr. Tara Jones

interventional cardiologist

common catheters

diagnostic coronary angiography

guiding catheters