Guide Catheter Selection for Coronary Interventions

Question 1

What is one of the most common coronary anomalies?

Answer 1

Separate ostia of the left coronary artery or a very short left main artery

Occurs in approximately 1% of patients and must be recognized by the operator.

Question 2

What is often better than obtaining inadequate angiograms of both vessels?

Answer 2

Selectively cannulating and obtaining separate angiograms of the LCx and LAD

Question 3

What catheter was used to selectively enter the LCx in this case?

Answer 3

JL 4 catheter

Question 4

What is the most likely maneuver to selectively cannulate the LAD?

Answer 4

Change to the next smaller Judkins curve size, in this case, JL 3.5

Question 5

What other maneuvers may allow cannulation of the LAD?

Answer 5

• Withdraw the JL 4 slightly and apply clockwise rotation
• Use a smaller backup guide like XB 3.0 or EBU 3.5

Question 6

What does CT coronary angiography help define?

Answer 6

The course of anomalous coronary arteries in difficult cases

Question 7

What is a common technical limitation when treating a distal stenosis?

Answer 7

The shaft length of the balloon or stent catheter (typically 135 cm)

Question 8

How can additional working length be preserved when using a guide?

Answer 8

By using a 90-cm guide instead of a longer one

Question 9

What is ideal for cannulating vein grafts to the RCA?

Answer 9

An MP catheter

Question 10

What is important for radial artery interventions?

Answer 10

Adequate guide catheter support

Question 11

What are the risks associated with larger lumen catheters?

Answer 11

• Increased potential for complications at the puncture site
• Higher contrast loads
• More trauma to the aorta

Question 12

What should be anticipated for guide catheter selection in CTO cases?

Answer 12

The need for adequate visualization and support

Question 13

What is an essential component in planning a rotational atherectomy case?

Answer 13

Knowledge of the maximum burr size

Question 14

What two transcatheter aortic valve bioprostheses are available in the US?

Answer 14

• Edwards Sapien 3 valve
• Medtronic CoreValve Evolut

Question 15

What is the design of the Sapien 3 valve in relation to coronary ostia?

Answer 15

Designed to be positioned below the coronary ostia

Question 16

What adjustment is often needed when using Judkins catheters for a right radial approach?

Answer 16

JL catheters should be downsized by 0.5 cm

Question 17

What could help engage the left main ostium when the catheter tip is just inferior to it?

Answer 17

Gentle clockwise rotation of the catheter

Question 18

What could be used to reconnect a shortened guide catheter?

Answer 18

A piece of sheath 1 Fr size smaller

Question 19

What is a common issue encountered with the Judkins catheter in patients of short stature?

Answer 19

The curve size of the Judkins catheter is too large

This can lead to difficulties engaging the left main coronary artery.

Question 20

What maneuver can help engage the left main coronary artery?

Answer 20

Gentle clockwise rotation of the catheter while the patient takes a deep breath

This helps to pull the ostium downward as the diaphragm moves.

Question 21

Which catheters are considered ‘longer’ than the JL 4 and may not fit?

Answer 21

• JL 5
• AL 2
• Voda 4

These catheters are typically not expected to fit due to their size.

Question 22

Where do saphenous vein bypasses to the left coronary typically arise from?

Answer 22

The left anterior surface of the aorta, superior to the native vessels

They usually arise superior to a bypass graft to the RCA.

Question 23

Which catheters often engage left-sided bypass grafts but do not provide robust backup support?

Answer 23

• JR 4
• LCB

HS and AL catheters provide additional support compared to these.

Question 24

What is the best catheter choice for a type III aortic arch?

Answer 24

A Simmons catheter

It requires reformation and manipulation to engage the innominate artery.

Question 25

What is essential equipment requirement when performing rotational atherectomy?

Answer 25

The guide catheter must be large enough to accommodate the atherectomy burr ## Footnote Good flow is also important for debris washout.

Question 26

What is a common challenge when using radial arteries for PCI?

Answer 26

Radial arteries can be quite small, potentially not allowing standard 6 Fr sheaths ## Footnote Operators often report success with 5 Fr guiding systems.

Question 27

What might pressure dampening indicate during angiography?

Answer 27

Possible significant left main disease ## Footnote It should be investigated to ensure no obstructive disease is present.

Question 28

What can diagnostic or guide catheters induce?

Answer 28

Ostial coronary artery dissections ## Footnote This can occur even with mild, insignificant disease.

Question 29

Which catheter shapes provide substantial backup for the delivery of stents?

Answer 29

* Amplatz catheter shape * XB family of curves * EBU family of curves * Voda curves ## Footnote The JL 4 shape provides minimal backup.

Question 30

What is a challenge when cannulating an anomalous RCA?

Answer 30

It is often very challenging to cannulate due to its atypical origin ## Footnote Standard left catheters may sometimes be utilized.

Question 31

What should be done if a guide catheter becomes kinked?

Answer 31

Rotate the catheter in the opposite direction to 'unkink' it ## Footnote A stiff wire may be used to assist in catheter removal.

Question 32

When should the waveform from the guide catheter be monitored?

Answer 32

Frequently, especially during maneuvers that could change the guide position ## Footnote This includes when seating the guide, before injections, and during equipment passage.

Question 33

What catheter should be used for enhanced support with a left-sided SVG?

Answer 33

An AL guide (AL 1, AL 1.5, or AL 2) ## Footnote Alternatively, LCB or HS catheters may provide additional support.

Question 34

What catheter is best for an RCA with an upward takeoff?

Answer 34

The AL 1 catheter ## Footnote Optimal coaxial alignment and backup support are desirable.

Question 35

Which guide is well suited to cannulate both the left and right coronary arteries?

Answer 35

The Ikari left guide ## Footnote It facilitates rapid angiography prior to PCI in STEMI settings.

Question 36

What is the primary purpose of the Ikari left guide?

Answer 36

To cannulate and image both the left and right coronary arteries ## Footnote This facilitates rapid angiography prior to PCI in the setting of STEMI.

Question 37

Why might the AL 2 guide be unsuitable for cannulating the RCA?

Answer 37

It is likely too long to cannulate the RCA well ## Footnote Although it is still possible to use it.

Question 38

Which guide is not able to cannulate the left main?

Answer 38

The JR 4 guide ## Footnote This guide is ineffective for this purpose.

Question 39

What is a limitation of the JL 3.5 guide?

Answer 39

It would not easily cannulate the RCA ## Footnote This limits its effectiveness in certain procedures.

Question 40

What is the EBU 4 guide routinely used for?

Answer 40

Left coronary intervention ## Footnote This guide is commonly utilized in interventional cardiology.

Question 41

True or False: The Ikari left guide is effective for rapid angiography prior to PCI in STEMI.

Answer 41

True ## Footnote Its design facilitates quick imaging and intervention.