Catheter Based Percutaneous Coronary Angiography The Byrne Identity

Catheter Based Percutaneous Coronary Angiography “The Byrne Identity” William O. Suddath, MD Director, Interventional Cardiology Fellowship Program Washington Hospital Center Institute of Cardiac and Vascular Disease

Evolution of Percutaneous Coronary Intervention 1 st PTCA NHLBI-PTCA Reg #2 n=1802 FDA Approval -USCI -ACS HFICA Approval NHLBI-PTCA Reg n=3079 FDA Approval-Cordis FDA Approval DES Cook Stent-bail out CMS Approval DES JJIS stent-elective HFICA Approval Stent Brachytherapy Clinical Trials -Dir Atherectomy -Stent -Rotablator -Excimer Laser FDA Approval ACS Multilink BSC Approval TAXUS

The Future Paradigm: Integrated Cardiovascular Care Hybrid Cardiac Endovascular Operating Room CV Surgery Percutaneous Intervention Hybrid Care Medical Therapy Traditional paradigm Future paradigm Vanderbilt Hybrid Lab

The Hybrid OR: The embodiment of the hybrid way of thinking: we are all “interventional cardiologists”, with different tools Vanderbilt Hybrid Lab 1. 2. Intra-operative imaging Combines the tools of the OR and cath lab to meet the needs of an increasingly complex patient population John Byrne, M. D.

Guidewires: Guidewires are described by: a) their length in centimeters b) their diameter in inches c) their tip confirmation e. g. a commonly used guidewire is the 175 cm, 0. 035 to 0. 038 inch, J-tipped wire, available exchange length, 220 cm.

150 cm 0. 035” Straight “GLIDEWIRE” with 3 cm flexible tip.

Catheters: Catheters vary from 50 to 125 cm in length. The 100 cm catheter is commonly used for LHC’s from the femoral artery approach. The outer diameter of the catheter is specified using French units, where one French unit {F} = 0. 33 mm, 6 F is 1. 98 mm in diameter. The inner diameter of the catheter is smaller than the outside diameter owing to the thickness of the catheter material.

Guides Diameters Lengths 6 F 7 F 8 F 9 F 10 F 130 cm 90 cm Sideholes Soft tips Variety of Shapes, variable Stiffness for backup support

Judkins Left

Judkins Right

Pigtail Catheter

Available Catheters: • • • IMA, IM “T”, IM “C” Right and Left Coronary Bypass Catheters Right IMA, 5. 2 F catheter RCA, 3 DRC LCA, sizes and configurations, JL 4+/-. • Guides: Similar in configuration, but are Stiffer, bulkier, range in size from 6 -10 F, lengths are essentially of two types, Tip configuration is important to the CA ostium.

Contrast Agents The necessary evil to angiography and PCI

CARE – Comparison with other prospective randomized trials Low osmolal (osmolality) Iso-osmolal (osmolality) Condition Statistical result Iohexol (844) Iodixanol (290) Coronary, CKD (SCr* 3. 1), 35% DM No difference 1 Iohexol (844) Iodixanol (290) Coronary, CKD (SCr 1. 5), 100% DM Iodixanol superior to iohexol 2 Ioversol (792) Iodixanol (290) Coronary, CKD (SCr 2. 0), 52% DM No difference 3 Iopamidol (796) Iodixanol (290) MDCT, CKD (SCr 1. 6) No difference 4 Iopamidol (796) Iodixanol (290) Coronary, CKD (SCr 1. 45), 41% DM No difference 5 Ioxaglate (600) Iodixanol (290) Coronary, CKD (SCr 1. 34, 48% DM Iodixanol superior to ioxaglate 6 *SCr: serum creatinine (mg/dl) 1 Chalmer and Jackson, BJR 1999 Rad 2006 2 Aspelin et al (NEPHRIC), NEJM 2003 3 Rudnick et al, (VALOR), ASN 2005 4 Barrett 5 Solomon et al (IMPACT), Invest et al (CARE), TCT 2006 6 Jo et al (RECOVER), JACC 2006

Syringe and Manifold Off Position Pressure Flush Contrast

Insertion and Flushing of the Coronary Catheter 1) Advance the catheter over the guidewire stopping at level of the left mainstem bronchus to remove the guidewire. 2) Aspirate to minimize any catheter contamination with blood clots then attach the catheter to the manifold system and clear the system of blood. 3) Advance the catheter cautiously over the arch. RISK: Avoid snagging the catheter tip on plaque that “may” be on the aorta or at the arch.

Views: Cranial views, RAO, AP, LAO for the LAD system.

Views: LCX is best visualized from the Caudal views, RAO, AP, LAO.

Views: RCA best visualized in the LAO straight, then cranial in the LAO, RAO.