Abstract
A new dedicated cardiac ventriculography catheter was specifically designed for radial and upper arm arterial access approach. Two catheter configurations have been developed to facilitate retrograde crossing of the aortic valve and to conform to various subclavian, ascending aortic and left ventricular anatomies. The “short” dedicated radial ventriculography catheter is suited for horizontal ascending aortas, obese body habitus, short stature and small ventricular cavities. The “long” dedicated radial ventriculography catheter is suited for vertical ascending aortas, thin body habitus, tall stature and larger ventricular cavities. This new design allows for improved performance, faster and simpler insertion in the left ventricle which can reduce procedure time, radiation exposure and propensity for radial artery spasm due to excessive catheter manipulation. Two different catheter configurations allow for optimal catheter selection in a broad range of patient anatomies. The catheter is exceptionally stable during contrast power injection and provides equivalent cavity opacification to traditional femoral ventriculography catheter designs.
1
Introduction
Radial approach for coronary angiography has been steadily increasing in the recent years . At present time, there are dedicated radial selective coronary angiography catheters as well as dedicated radial percutaneous coronary intervention guiding catheters available . Dedicated ventriculography catheters have not been developed for radial and upper arm vascular approach.
Left ventriculography is performed at the time of diagnostic cardiac catheterization for evaluation of left ventricular structure and function. In addition, assessment of wall motion abnormalities, quantification of mitral regurgitation and presence of a ventricular septal defect can be diagnosed with the use of ventriculography.
Ventriculography is traditionally accomplished with pigtail catheters as they allow for injection of contrast in the left ventricle with a power injector through multiple side-holes in order to minimize arrhythmias and prevent myocardial staining or perforation. Alternatively, dedicated radial coronary diagnostic catheters with end and side holes (e.g., Tiger or Jacky, Optitorque™, Terumo Medical Corporation) have been used for ventriculography although their use has been on occasion associated with myocardial staining . These catheters do not allow for very rapid injection of large contrast volume as their position in the left ventricle is inherently less stable than pigtail-type catheters due to recoil associated with brisk injection of contrast with power injectors.
Most currently available pigtail ventriculography catheters have been designed by Judkins and are available in “straight” and “angulated” configurations. The “angulated” pigtails are available with 145 and 155° angulations .
Currently available catheters, namely straight and angulated pigtail catheters, when inserted from the radial approach tend to point towards the non-coronary cusp and are frequently difficult to rotate into the left cusp. This catheter behavior, pointing away from the left cusp and greater difficulty in positioning into the left cusp may significantly prolong insertion time, increase catheter manipulation, patient and staff exposure to fluoroscopy and may increase propensity for radial artery spasm.
To overcome this limitation of currently available catheters, a dedicated radial ventriculography catheter was developed.
1.1
Catheter design
This novel catheter has a multiangulated design. The introduction of an additional angulation to the pigtail catheter design compensates for the difficulty encountered with classic ventriculography catheters designed for femoral approach. In particular, this additional angulation allows for better torque response and control of the catheter in short ascending aortas.
There are two different configurations available. The “ short ” multiangulated dedicated radial pigtail catheter is specifically designed for short ascending aortas present in obese patients, women or horizontal aortas seen with advanced age and atherosclerotic disease ( Fig. 1 ). Such “short” and “horizontal” ascending aortic pattern is frequently seen in obese individuals as the diaphragm pushes the aorta cephalad. The “ long ” multiangulated dedicated radial pigtail catheter is primarily dedicated for elongated, vertical aortas, tall patients with vertical hearts as frequently seen in patients with extensive smoking history and chronic obstructive pulmonary disease ( Fig. 2 ).
The catheters have been developed and successfully tested in both 110 cm and 125 cm lengths. The 125 cm design appears quite beneficial in patients with subclavian tortuosity frequently encountered in women and elderly patients.
The catheters are available in 4 French, 5 French and 6 French sizes.
1.2
Insertion technique
The catheter is advanced in standard fashion with the over-the-wire approach in the ascending aorta. Most commonly, a standard J-tipped wire is best suited for this application. After the catheter is placed in the ascending aorta, the J-tipped wire is withdrawn and the tip of the pigtail catheter is allowed to recoil to its baseline shape. It is frequently quite advantageous to keep the J-tip wire in the catheter, approximately 10 cm from the distal tip, to facilitate torqueing and subsequent advancement through the aortic valve.
The catheter is then rotated in clockwise fashion into the left coronary cusp. Once it slightly prolapses in the left cusp it is gently withdrawn and simultaneously rotated in counterclockwise fashion. With this maneuver, and owing to its stiffness it easily prolapses into the left ventricle. On occasion, the J-tip wire can be used to help cross the aortic valve and position the catheter into the left ventricular cavity.
The catheter is then positioned in the mid-ventricular cavity and its relation to the left ventricular apex verified in a 30° right anterior oblique (RAO) projection ( Fig. 4 ). The position of the catheter between the papillary muscles and relation to the lateral wall is best verified in a 45–60° left anterior oblique (LAO) projection ( Figs. 5-8 ).
