2 Arterial and Venous Access and Hemostasis for PCI

Connie N. Hess, Sunil v. Rao, Kimberly A. Skelding, Morton J. Kern, Mitchell W. Krucoff

Techniques for vascular access for interventional procedures are identical to those used for diagnostic catheterization. The initial approaches, assessment, and methods have been described in detail in The Cardiac Catheterization Handbook, 5th edition, and will be reviewed here with emphasis on interventional procedures. The site and type of access, most commonly either the femoral or radial artery, are determined by the anatomic and pathologic conditions and anticipated PCI techniques required.

As a first step, to avoid known pitfalls and potential complications, it is helpful to understand any previous difficulties encountered during diagnostic procedures. As is the case with diagnostic studies, assessment of all arterial pulses before and after the procedure is mandatory. For both diagnostic and interventional procedures, vascular access is the most common cause of procedural morbidity.

Percutaneous Femoral or Radial Artery Approach

Because femoral access is the most commonly used technique in the United States and because of the need for large-diameter interventional equipment, the femoral artery approach is often preferred to the radial artery approach. However, in recent years most labs using 6F guide catheters can easily employ the radial approach for both the diagnostic and the subsequent PCI. The radial approach has significantly fewer access-related complications and, in some studies, better late outcomes. The discussion of the radial technique will follow the femoral approach although operators familiar with current clinical data would advocate “radial first” when possible. Conditions in which radial (or, rarely, brachial) artery access should be favored are listed in Table 2-1.

^{Table 2-1} Conditions in Which Radial Artery Access Should Be Favored

Femoral Artery Puncture Technique

The proper position for femoral artery puncture should be in the common femoral artery, defined as that segment above the femoral artery bifurcation and below the internal epigastric artery (Fig. 2-1). This target zone can be identified by visualizing the head of the femur with a metal marker indicating the planned path of the needle by fluoroscopy. In a manner identical to diagnostic vascular access, the operator locates the artery and administers local anesthesia (see The Cardiac Catheterization Handbook, 5th ed., Chapter 2). Single front wall puncture (Fig. 2-2) is highly desirable for two reasons:

1. Reduces chances of bleeding in the setting of potent anticoagulation and antiplatelet agents.

2. Facilitates successful vascular closure device placement; if a second site puncture occurs, a vascular closure device cannot be used with confidence in obtaining hemostasis.

Figure 2-1 Femoral angiogram (left) AP view, (right) lateral view. The common femoral artery (CFA) has the inferior epigastric artery and bifurcation of the superficial and profunda femoral arteries as the top and bottom markers. Yellow dotted line is middle of femoral head. Lower red line is bifurcation of superficial and profunda femoral arteries; top red line is lower border of inferior epigastric artery. The arrow shows the target zone for proper puncture in the common femoral artery.

Figure 2-2 Technique of single-wall arterial puncture. A. Parasagittal cross-sectional diagram of inguinal region at level of femoral artery. B. Correct needle entry position is below inguinal ligament and above femoral artery bifurcation. Correct access is particularly critical for procedures.

(From Kulick DL, Rahimtoola SH, eds. Techniques and applications in interventional cardiology. St. Louis, MO: Mosby, 1991: 3.)

For these reasons, the supervising physician for PCI as well as diagnostic procedures should ensure proper arterial access in all patients, a fact especially important for those patients going on to intervention. Multiple punctures will be a source of bleeding and potential complications, including retroperitoneal hematoma, femoral pseudoaneurysms, or arteriovenous fistula (AVF) postprocedure. Femoral angiography before PCI is highly recommended to ensure proper access and justify deferment of proceeding to elective PCI should a high stick be identified with its potential for retroperitoneal bleeding. Femoral angiography after sheath insertion or before undertaking PCI will confirm placement in the common femoral artery.

When an interventional procedure is performed on a separate day after the diagnostic catheterization, femoral access on the contralateral side or radial access should be considered. Puncturing the same groin soon after diagnostic access may be associated with a higher incidence of bleeding or infection. Reaccess in punctures closed with some vascular closure devices can be performed. However, repuncture in an Angio-Sealed femoral artery is not recommended before 90 days; those closed with StarClose or Perclose may be reaccessed immediately, although there are two reports from the many thousands of patients noting the remote chance of reentering the central opening of the StarClose clip.

Key Points for Femoral Arterial Access for Interventional Procedures

1. Consider radial access first because of its lower rate of femoral bleeding complications.

2. In obese patients, place a hemostat or marker over the planned puncture site and fluoroscopically visualize the femoral head.

3. Consider using a Doppler needle or other ultrasound guidance for deep or difficult femoral punctures.

4. If anticipating need for large bore equipment (e.g., rotablator or two stents for treating a bifurcation), use a ≥7F arterial sheath.

Percutaneous Femoral Vein Puncture

Femoral vein puncture is performed like the arterial puncture, as described in The Cardiac Catheterization Handbook, 5th edition, chapter 2. Indications for femoral venous sheath placement in patients undergoing PCI include the need for additional intravenous access for fluids and medications, a temporary pacemaker, or pulmonary artery pressure monitoring. Caution should be used to avoid inadvertent additional arterial punctures. For this reason, if femoral vein access is needed, start with the vein access before arterial puncture. If the artery is inadvertently accessed, place the arterial sheath and then angle slightly more medially with the next puncture.

Radial Artery Access for PCI

The technique of radial artery access for diagnostic and interventional procedures has gained worldwide acceptance. Kiemeneij of the Netherlands pioneered the radial approach for coronary interventions, increasing the success rate, improving patient comfort, and providing a method for excellent hemostasis in the fully anticoagulated patient.

The transradial interventional (TRI) approach has several distinct advantages over femoral access. Bleeding complications from the radial artery approach are negligible compared to those of femoral access. The radial artery is easily accessible in most patients and is not located near significant veins or nerves. The superficial location makes for easy access and control of bleeding. In patients with a normal Allen’s test, no significant clinical sequelae occur after radial artery occlusion because collateral flow to the hand occurs through the ulnar artery. Patient comfort is enhanced with the ability to sit up immediately after the procedure and when pre-medications wear off, they may walk around the room or be discharged.

While the fundamental principles of catheter manipulation remain the same as those used in femoral procedures, TRI is technically more variable. Basic changes in approach by both the operator and the catheterization lab staff are required to overcome the “radial first” learning curve. Some of the practical challenges encountered when learning to perform TRI and strategies to overcome them are highlighted in Table 2-2.

^{Table 2-2} Challenges to Starting a Radial Program

Patient setup

Prep wrist with patient’s arm at his or her side (radial artery parallel to femoral artery)

Prep femoral artery simultaneously in case of crossover

Use either a rectangular platform or 2 “banjo” arm boards underneath patient’s arm to create a working space distal to patient’s hand

Place towels on working space to elevate working space to level of wrist

For left radial cases, elevate left arm using pillows to bring left radial above left groin or have patient bring left arm across body after obtaining left radial artery access

Radial artery access

Small-caliber artery

Check contralateral radial artery

Spasm

Intra-arterial nitroglycerin, calcium channel blockers

Patient sedation

Use smaller French size catheters

Repeat access

Check patency of artery (ultrasonography or reverse Allen test*); obtain access more proximally

Traversing the radiobrachial region

Radiobrachial angiogram for any resistance to advancing the wire or catheter

Radial loop: use 0.014-inch hydrophilic wires to traverse and straighten loop

Consider femoral access bailout if unable to traverse radial loop or if there is significant patient discomfort

Traversing the chest arteries

Have patient take a deep breath to straighten subclavian/innominate arteries and subclavian/innominate-aortic junction to direct catheter to ascending aorta

For extreme z-curves, use hydrophilic 0.035-inch wires to direct catheters into ascending aorta

Engaging the coronary arteries

Judkins curves: use longer JR curve (e.g., JRS), shorter JL curve (e.g., JL3.5)

Specialized curves (e.g., Kimny, Tiger, Jacky, Ikari, Amplatz)

Previous CABG: use left wrist with JR4/JL4 catheters, multipurpose catheter, or specialized curves

From Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 2010;55:2187–2195.

Clinical Evidence Favoring TRI

The radial approach offers several distinct advantages over femoral access without sacrificing procedural success and may be even more attractive given the reclassification of femoral closure devices as a class III recommendation. While there is a well-documented learning curve for transradial catheterization, data from both observational studies and randomized trials suggest that increased operator experience and transradial case volume are associated with significant reductions in procedural failure and, ultimately, no difference in success rates between radial and femoral approaches. Femoral artery access site complications, including retroperitoneal hematoma, AVF, pseudoaneurysm, arterial dissection, and neuropathy, are important contributors to patient morbidity and mortality, even when femoral closure devices are used. These complications are all distinctly rare in radial procedures.

With its superficial location, complications at the site of radial puncture are less common, noticed earlier, and easier to manage. Rates of major bleeding are significantly lower for transradial procedures, even in populations at high risk for arterial access complications, such as females and the elderly (Fig. 2-3). Data from patients of all ages suggest that this reduction in bleeding may translate into reduced rates of death and ischemic events. In addition, patient comfort and satisfaction are enhanced by transradial access, as patients can sit up immediately postprocedure and ambulate as soon as their sedation has worn off. Compared with femoral technique, transradial catheterization leads to improved quality of life postprocedure and is preferred by patients.

Figure 2-3 Bleeding and vascular complications in radial and femoral PCI.

(Adapted from Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2008;1:379–386.)

Patient Selection for TRI

TRI presents an important first-line option for many patients undergoing coronary intervention, but proper patient selection is central to achieving optimal outcomes. Early in the learning curve, gaining experience with diagnostic procedures in patients with less complex anatomy and conditions is recommended. As experience and confidence increase, patient selection can be liberalized.

While there is some debate, confirmation of a normal Allen’s test (see below) is strongly recommended. If the Allen’s test is abnormal on one side, the contralateral side should be evaluated before changing to femoral access.

In general, TRI is avoided in patients in whom:

a. The radial artery is being considered for use in coronary artery bypass graft surgery or in whom hemodialysis via an AVF may be necessary, as well as in patients with an existing AVF.

b. There is known upper extremity vascular disease, such as severe atherosclerosis, extreme tortuosity, or vascular anomalies, or those with vasospastic disorders, including Raynaud’s or Buerger’s disease.

c. The procedures will likely to require 7F or larger guide catheters.

In addition, the presence of right- or left-internal mammary artery graft conduits may be less accessible from the contralateral wrist.

TRI is an especially good option for patients on systemic anticoagulation with elevated INR (international normalized ratio) and patients with suspicion of descending aortic dissection.

Use of TRI in very time-sensitive settings, such as ST-elevation acute myocardial infarction, remains controversial. Studies suggest that transradial catheterization can be performed without significant delays in door-to-balloon time and without increasing procedure duration, radiation exposure, or contrast use in experienced labs with experienced operators. In all cases, these guidelines for patient selection should be balanced against the risks and benefits of radial versus femoral access, as even a patient with an abnormal Allen’s test may benefit from TRI under certain circumstances.

Anatomy for Radial Access

Knowledge of the anatomy of the vessels of the upper extremity and aortic arch is essential information for becoming a TRI operator. The aortic arch gives off the great vessels: the innominate artery on the right and the common carotid and subclavian arteries on the left. The innominate artery becomes the right subclavian artery after the takeoff of the right common carotid. The lateral margin of the first rib demarcates the transition from subclavian artery to axillary artery. At the inferior border of the teres major muscle, the axillary artery continues as the brachial artery, which then bifurcates in most patients into the radial and ulnar arteries below the elbow. Some patients will have an anatomic variant in which the radial artery originates higher than the elbow. The radial artery then continues along the lateral aspect of the forearm into the wrist, where it passes over the scaphoid and trapezium bones and divides into the deep and superficial palmar arches. The flexor retinaculum overlies this area of the wrist. The deep and superficial branches of the radial artery communicate with corresponding divisions of the ulnar artery to complete the two palmar arches and provide dual, collateral blood flow to the hand in most patients (Fig. 2-4). Operators should familiarize themselves with the relevant anatomy to avoid cannulation of the radial artery too distally and to prepare for anatomic variants that may make traversing the path from radial artery to ascending aorta challenging.

Figure 2-4 Radial artery and the anatomy of the hand.

Use of the Allen’s Test

A strong recommendation for the radial procedure is the performance of the Allen’s test. The Allen’s test assesses the adequacy of the palmar arch and ulnar flow. It is performed as follows: The patient makes a fist pushing blood from the hand. The radial and ulnar arteries are compressed and simultaneously occluded. When the hand is opened, the palm appears blanched. Release of the ulnar artery should result in return of pink hand color within 8 to 10 seconds. (Fig. 2-5)

Figure 2-5 Manual Allen’s test. A, Normally the palm is pink. B, A fist is made and the radial and ulnar arteries are compressed. C, The hand is open and blanched after compression of both ulnar and radial artery. D, The palm is pink after release of ulnar artery with radial artery occluded.

Another and more objective measurement of satisfactory ulnar flow can be documented by pulse oximetry. Using the pulse oximeter, the pulse wave is displayed with both arteries open (Fig. 2-6a). The radial artery is then compressed and the pulse wave of ulnar flow observed (Figs. 2-6b, 2-6c). A reverse Allen’s test can also be performed by occluding the ulnar artery. It is recommended for patients with a history of previously accessed radial arteries either for catheterization or arterial blood gases. The results of the oximetric Allen’s test are divided into four grades of waveforms: type A, no change in pulse wave; type B, damping of waveform that returns to normal within 2 minutes; type C, loss of phasic pulse waveform that returns within 2 minutes; type D, loss of pulse waveform without recovery within 2 minutes. Although use of the Allen’s test and grading of the results for patient selection safety concerns may not be well supported by data, in some areas, this may be considered standard of community practice. In such cases, radial artery cannulation is recommended with types A or B results, can be considered with type C results, and contraindicated with type D results.

Figure 2-6 Oximetric Allen’s test. A, Before radial or ulnar artery compression, pulse oximeter waveform is normal. B, Waveform is flat when both radial and ulnar arteries are compressed. C, Pulse waveform is normal when only ulnar is released. Radial artery is still compressed. This is a type A response. Type B is blunted waveform, and type C is flattened wave.

Room and Patient Setup

Transradial coronary angiography can be performed from either the right or left arm. In general, the right arm is more convenient, as most catheterization labs are set up with the operator on the right side of the patient and the video screens on the left. Use of the right arm obviates the need to reach over the patient. Recent comparisons have suggested that left radial access with a more similar approach to the ascending aortic as that of femoral angiography may take less time and use less contrast than the right radial approach, especially early in the learning curve. During catheterization via the left radial artery, such as in patients with a left internal mammary artery graft, the left arm should be comfortably adducted over the patient’s body toward the operator (standing on the right side) after access has been obtained. The pulse oximeter is placed on the index finger of the ipsilateral hand used for radial access. Some labs display the pulse oximetry waveforms at all times.

For either right or left radial approaches, correct positioning and preparation of the patient’s arm are important for successful arterial access (Fig. 2-7). The arm board, typically a rectangular or banjo-shaped board, is securely placed under the patient’s torso to provide support for the patient’s arm and catheterization equipment. After the distal forearm has been shaved, the arm is placed on the arm board. In some labs the arm is placed at the patient’s side, such that the radial and femoral arteries are in parallel. In other labs, the arm is moved to the patient’s side after arterial access. This placement next to the leg decreases operator radiation exposure and removes the need for specialized drapes. For right radial cases, towels are stacked underneath and around the patient’s arm to provide a level work space that is at the same elevation as the anterior surface of the patient’s body. The wrist is supinated and hyperextended slightly, using a rolled towel or other soft object placed under the wrist. Over-hyperextension of the wrist should be avoided, as the arterial pulsation can be blunted by this maneuver. The arm can be stabilized with tape or an elastic bandage. An optional short (elbow to hand), cushioned arm board typically used for arterial pressure lines can also help to secure the wrist in an optimal position (Fig. 2-8). The short arm board is especially useful for left radial cases and allows for adduction of the whole arm toward the operator while maintaining correct positioning of the wrist.

Figure 2-7 A, Right arm is positioned extended on arm board. B, After radial sheath insertion, the arm is moved to the patient’s hip for introduction of catheters and C, performance of angiography and intervention.

Figure 2-8 Draping of the hand with sterile towels.

After proper positioning of the patient’s arm, a sterile field is created. A sterile top drape with a circular adhesive cutout in the middle is placed over the wrist, exposing the most distal portion of the forearm where the point of maximal radial arterial pulsation is felt. Several sterile towels are then draped around the sides of the exposed area. An innovative way to keep the patient’s hand both sterile and free of blood during the procedure is to place a sterile glove on the patient’s hand prior to the top drape (Fig. 2-9). The femoral artery should be prepped and draped simultaneously in the event of conversion to a transfemoral approach (although converting from one radial to the other is frequently a better option) or the urgent need for a balloon pump.

Figure 2-9 A, B, An alternative method to drape the hand is to cover the hand with a sterile glove.

Radial Artery Access and Sheath Introduction

The most common cause of failed transradial catheterization is unsuccessful radial arterial access, and the first radial attempt has the highest chance of success: an injured artery may spasm, making subsequent attempts more difficult. Operators should thus proceed slowly and carefully, especially when first learning to obtain radial artery access. Key to reducing local vasospasm is general sedation and mild analgesia coupled with adequate but limited local anesthesia.

Once draped, the radial pulse is palpated. The ideal puncture site is 1 to 2 cm proximal to the radial styloid, the bony prominence of the distal radius. Sites near the radial styloid risk puncture of the radial artery after its bifurcation and may make threading the guidewire difficult through a stretched and flattened radial artery. Extremely proximal punctures are more difficult to compress and can result in hematoma formation. A small amount (no more than 1 mL) of local anesthetic is injected subcutaneously, raising a small wheal similar to a tuberculosis skin test. Larger amounts of anesthetic can obscure the pulse. The course of the radial artery is fixed with the index and middle fingers of the nondominant hand. Using the other hand, the micropuncture catheter-over-needle system is inserted with the bevel facing up at a 30- to 45-degree angle to the skin along the direction of the radial artery until a flashback of blood is visualized. The system is advanced until the back wall of the vessel is punctured and blood flow stops. This is known as a “through and through” technique (Fig. 2-10). Occasionally, no flashback of blood is observed, although the operator is confident of an intra-arterial puncture. The catheter-needle system should continue to be advanced to complete the back wall puncture in this situation. The needle is then removed, and the catheter is withdrawn until its tip is intraluminal, as confirmed by freely flowing blood. A 0.018- or 0.025-inch straight-tip or slightly angulated guidewire is gently inserted using a twirling motion. There should be no or little resistance to wire introduction: if resistance is encountered, fluoroscopy should be used to immediately visualize the position of the wire. Once the wire is securely and freely in the vessel, the cannula is removed over the wire. Figure 2-11 shows the steps for radial sheath insertion.

Figure 2-10 “Through and through” technique for radial puncture.

(Reprinted from Nguyen TN, Colombo A, Hu D, et al., eds. Practical handbook of advance interventional cardiology, 3rd ed. Copyright (2008) with permission from Blackwell.)

Figure 2-11 Radial artery access and sheath introduction. Once draped, the radial pulse is palpated. The point of puncture should be 1 to 2 cm cranial to the bony prominence of the distal radius. Administer small amount of lidocaine into the skin. Use the micro-puncture needle at 30- to 45-degree angulation; slowly advance until blood pulsates out of needle. It will not be a strong pulsation due to small bore of needle. Fix needle position and carefully introduce 0.018 guidewire with twirling motion. There should be little or no resistance to wire introduction. Remove needle. Make small incision over wire in preparation to introduce sheath (this step may be optional with some ultra-tapered dilators). A, Advance sheath over wire into artery. If sheath moves easily, advance to hub. If resistance is felt with sheath halfway in artery, remove wire and administer vasodilator cocktail. Reinsert wire and continue to advance sheath. B and C, Secure sheath with clear plastic dressing or suture. D, After sheath is positioned and flushed, the arm can now be moved to patient’s side for catheter introduction.

Some operators prefer single anterior wall puncture of the radial artery using a bare metal needle. After the initial flashback of blood, the needle is advanced a millimeter further to ensure that the whole tip, not just the tip of the bevel, is intraluminal. If blood continues to flow freely, the needle is fixed, and a 0.025-inch straight-tip wire is advanced into the artery. The needle is then removed. Note that only metal guidewires should be used with bare metal needles, as plastic-coated wires used in this scenario can be shredded if they are pulled back against the bevel.

Most radial artery sheaths have a tapered tissue dilator and vary in French size and length, ranging from 10 to 36 cm long. In our experience, the combined use of a graduated dilator system and hydrophilic-coated sheath typically obviates the need for a skin nick prior to sheath insertion. Some operators still prefer to make a small incision over the wire in preparation for sheath introduction. Hydrophilic-coated sheaths can reduce radial artery spasm and pain upon sheath withdrawal, as well as postprocedural inflammatory reactions. Some operators advocate using long sheaths for patient comfort and better catheter manipulation. In patients with smaller stature, however, long sheaths may reside in the brachial artery, and the impact of using longer sheaths on long-term patency of the radial artery is unknown. After loading the sheath onto the wire, the sheath is held close to the distal tip to avoid bending of the equipment. Steady but firm pressure is applied until the dilator has advanced into the artery. The same steady pressure is used to advance the sheath past the dilator–sheath transition point into the artery. If there is resistance, use wet gauze to make the hydrophilic sheath slicker; gentle rotation during advancement also can facilitate sheath insertion. Alternatively, the wire can be removed with the sheath halfway in and then reinserted after administration of a vasodilator cocktail through the dilator. Once the sheath is fully advanced to the hub, the dilator and guidewire are removed together, and the sheath is flushed. A large Tegaderm placed over the head of the sheath can secure the system without the need for sutures. A nick in the Tegaderm at the opening of the sheath diaphragm allows ready access for catheters and guidewires.

Concomitant Medications

Medications are crucial adjuncts to successful TRI, as the radial artery is very vasoactive, and flow around the sheath at the site of radial access is sluggish, increasing the risk for thrombus formation. Anxiety and high sympathetic tone are significant contributors to vasospasm, making the use of local anesthetic, sedation, and analgesia important factors in keeping patients comfortable and relaxed. Once access is achieved, intra-arterial injection of a spasmolytic agent, such as nitroglycerin, verapamil, diltiazem, adenosine, or papaverine, is essential for minimizing vasospasm and discomfort. Calcium channel blockers may be longer lasting than nitrates, although they are also associated with an intense burning sensation and should be diluted to mitigate discomfort. Spasmolytics can be repeated as necessary throughout the procedure during catheter exchanges, if hemodynamics allow. For anticoagulation, weight-adjusted unfractionated heparin (UFH) 40 to 70 U/kg up to 5000 U is administered to prevent thromboembolic complications and radial artery occlusion. This can be given immediately after insertion of the radial artery sheath, although some operators prefer to wait until successful passage of a guidewire into the ascending aorta has been achieved in case of need to convert to the femoral approach. Administration of UFH intravenously is preferred, as it causes less discomfort than intra-arterial injection. A sample regimen of drugs and doses used in our lab is provided in Table 2-3.

^{Table 2-3} Medical Regimen for Radial Catheterization

Before Procedure

After Sheath Insertion (Before Catheter Insertion)

Intra-arterial spasmolytic

Nitroglycerin 100-200 mcg for most patients

Verapamil 2.5 mg diluted into 10 mL of blood or saline

Intravenous unfractionated heparin 40 U/kg bolus up to a maximum of 5000 U

After Procedure and Before Sheath Removal

Verapamil 1-2.5 mg (optional) IA

Angiographic Catheter Selection

Careful catheter selection for the radial approach is important. Table 2-4 lists the most commonly used catheters. The standard preformed diagnostic Judkins or Amplatz catheter shapes may be used but require more manipulation for selective engagement of the coronary ostia. For selective engagement of the left coronary ostium, a Judkins left 3.5 catheter is typically used. Several catheters that can be used to approach both the left and the right coronary arteries have been developed (Fig. 2-12). A decrease in catheter exchanges has been shown to decrease the incidence of spasm. Use of the left radial artery approach provides easier manipulation of the standard preformed Judkins shapes with minimal effort. The left arm should be brought over the abdomen so that the operator can work from his or her usual position on the right side of the patient.

^{Table 2-4} Most Commonly Used Catheters for Radial Coronary Angiography

Right Coronary Artery

1. Judkins right catheter

2. Amplatz right catheter

3. Amplatz left catheter

4. Jacky

5. Tiger, special shapes

Left Coronary Artery

1. Jacky

2. Tiger, special shapes

3. Judkins left catheter (typically 3.5 cm)

4. Multipurpose catheter