Cardiac Catheterization

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    Introduction

    • Two types of angiography
      • Selective - engaging each coronary artery and injecting contrast dye into each
      • Non-Selective - putting contrast dye into the aortic root to visualize coronaries
    • Arterial Access
      • Femoral (traditional)
      • Radial (newer)
    • Types of introducers for cardiac cath: (increasing in size)
      • 5 Fr Slender
      • 5 French
      • 6 Fr Slender
      • 6 French
      • NOTE: Slender catheters have the same luminal diameter, but are smaller (can kink easier)
      • NOTE: Usually if PCI is planned, go with a larger catheter (i.e. 6Fr), but some do PCI with 5 Fr.
    • Types of catheters for angiography
      • Universal Catheters (engaging both L and R coronaries)
        • Tigg (available at UH)
          • Also has side-holes to prevent complete occlusion
        • Tiger
        • Kimny
      • Selective Catheters
        • Judkins Right (JR)
        • Judkins Left (JL)
        • Amplaz R and L (AR, AL)
        • Number after the catheter indicates the size of the curve on the end (i.e. JR-4 has a wider curve, JR-3 has a narrower curve).
        • If you find that the JL4 catheter always ends up below the coronary osteum, use JL3.5 or 3
      • Special Catheters
        • IMA Catheter - For LIMA cannulation from the L-arm.
        • PigTail Catheter - for LV and root shots (some have a bend on the end, others dont)
      • Guiding Catheters
        • aka Extra Backup (i.e. EBU catheters)
        • These are for coronary wires, and stents
        • They are thicker, wider, and curve from one side of aorta to another, which provides support for wires and stents.
        • They are considered more dangerous because they are thick and stiff
    • Types of wire:
      • Large Wire
        • J-tip 0.035'' guidewire
      • Coronary Wire
        • BMW 
        • etc..

     

    Technique - Radial Approach

    • Most use the micropuncture kit that includes a puncture needle and a wire
    • Ideal puncture location is below radial styloid (which is more proximal than art lines)
    • Before the procedure ensure you check for dual arterial supply using methods:
      • Allan Test
      • Barbeau Test   (Barbeau et al 2004) Am. Heart J.Barbeau.png
        • Put sat probe on thumb, occlude radial and ulnar, wait for sat waveform to flatten
        • Then release ulnar artery and see if waveform recovers
        • Responses grouped in  types A-D
        • A = normal waveform, B = slightly dampened, becomes normal in 2min
          C = remains flat, pulsation comes back after 2 min.  D = flat all the time
        • Don't use radial if Barbeau Class D
    • Vasodilators Must Be Given (radial only)
      • Verapamil 2.5-5mg +/- nitroglycerin 200mcg into sheath
    • Anticoagulation must be given (radial only)
      • heparin 70u/kg IV or bivalirudin if PCI
    • Most catheters were made for femoral approach, so sometimes can be hard to use them

     

    Engaging Coronaries

    • Move wire and catheter into ascending aorta (can ask deep breath to facilitate lowering of heart)
      • Do this in AP projection
    • Engage in LAO

    Cannulating Grafts

    • A bit trickier because you don't know where they take off from
    • Usually L-sided grafts are on the L-aorta and above L-main
    • Usually R-sided grafts are on the R-aorta above R-main (check previous caths for clues, and use sternal wires as landmarks)
    • Typically LIMAs are easier to cannulate from the L-radial approach (many attendings use L-radial and bring arm over the patient to work from the right side)
      • Also easier to cannulate from the femoral arteries
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