Fig. 14.1
Different sequence of catheters in performing primary PCI including multiple catheters technique and single catheter technique. STEMI ST-segment elevation myocardial infarction, JL/R judkins left or right catheter, DMP diagnostic multipurpose catheter, IRA infarct-related artery, NIRA non infarct-related artery, GC guiding catheter, PCI percutaneous coronary intervention,CA coronary angiography
Type 1: Start with multiple diagnostic catheters (for example: JR for RCA or JL for LCA) or one single diagnostic catheter (Tiger or Kimny) for complete coronary angiography followed by using a guiding catheter to perform PCI of the culprit artery [9].
Type 2: Start with a diagnostic catheter for the presumed non-culprit artery based on the Electrocardiogram (ECG) identification followed by guiding catheter selection to treat the culprit artery [9].
Type 3: Start with diagnostic catheter for angiography of the presumed culprit artery followed by guiding catheter selection for primary PCI or start with guiding catheter for angiography and intervention of the presumed culprit artery and then performed contralateral diagnostic angiogarphy [10].
Type 4: start with a guiding catheter for the angiography and PCI of the “culprit artery” followed by contralateral diagnostic angiography [11].
Type 5: Start with a single guiding catheter for the non-culprit artery coronary angiography and then performed primary PCI for the culprit artery.
Simply, three types of method were also applied in clinical practice, The definition, advantage and disadvantages of different approaches regarding coronary angiography before primary PCI seen Table 14.1.
Table 14.2
Recent studies demonstrating single guiding catheter for transradial primary PCI
First author (Ref. #) | Year | Study type | Default access | Sample size | Guide catheter | Median procedure time (min) | Success rate % (CA) | Success rate %(PCI) | |
|---|---|---|---|---|---|---|---|---|---|
LCA | RCA | ||||||||
Roberts et al. [12] | 2011 | Observational | Right | 42 | Q | 47 | 100 | 85 | 85 |
CHOW et al. [13] | 2012 | Retrospective | Right | 162 | Ikari left (IL) 3.5 | 34 | 100 | 95 | 98.8 |
Malaiapan et al. [14] | 2013 | Observational | Right | 39 | 6 F Kimny | 50 | 100 | 100 | 100 |
Moon et al. [15] | 2012 | Observational | NA | 31 | 6 Fr RM 3.5 | NA | 96.7 | 96.7 | |
Table 14.1
Different approaches regarding coronary angiography before primary PCI
Method | Definition | Reperfusion time | Revascularization strategy |
|---|---|---|---|
Ipsilateral approach | Start the procedure with a guiding or diagnostic catheter for the angiography followed by PCI of the “culprit artery” (based on ECG) | Reduced | No change |
Contralateral approach | Start with a diagnostic or guiding catheter for the “non-culprit artery” (based on ECG) followed by angiography and PCI of the culprit vessel | Increase | May be modified after get the knowledge of multivessel or left main disease before Primary PCI |
Full diagnostic catheterization | Completing the angiography of left and right coronary arteries with diagnostic catheters before primary PCI | Increase | May change |
A few studies have examined the effect of a single universal guide catheter such as Ikari or Kimny catheter on reducing catheterization laboratory door to balloon (CTB) times and DTB times and showed using that a single guiding catheter can reduced CTB time (Table 14.2).
14.4 Manipulation of the MAC Guiding Catheter
The Multi-aortic Curve (MAC) guiding catheter (Fig. 14.2 Medtronic, Inc.) is a long-tip guide that provides backup from the contralateral aortic wall. MAC guiding catheter was advanced over a 0.035-in. wire, the catheter tip will typically end up in the left coronary sinus. Withdrawing the wire but keeping the guidewire in the catheter prevents kinking of the catheter. Cannulation of the RCA using a MAC guiding catheter is performed in left anterior oblique (LAO) projection. Maneuver is basically same as with the JR catheter if failed, formed a smaller U-shaped curve in the right sinus with its tip directed to the left coronary orifice. Rotate the catheter clockwise until its tip engage the RCA (Fig. 14.3a–d).
Fig. 14.2
MAC 3.5 guiding catheter designed by Medtronic INC., (a) natural shape, (b) the wire modifies the MAC catheter to simulate a Judkins Right conformation
Fig. 14.3
Catheterization of Right coronary artery (RCA) in the left anterior oblique projection using MAC3.5 guiding catheter, (a) formed a small u shape curve in right cusp with it tip directed to left; (b) rotate the catheter clockwisely; (c) its tip points toward RCA; (d) slightly pull or push the catheter and engage RCA (white arrow)
Cannulation of the LCA is also performed in the LAO projection. For selective engagement of the left coronary ostium after finishing coronary angiography of RCA, MAC require more manipulation while it is gently pull the catheter toward the contralateral aortic wall (Fig. 14.4a–c), push the catheter at the moment until it looks like a U-shape (Fig. 14.4d–f), slightly rotate the catheter tip clockwise toward the left sinus Valsalva (Fig. 14.4g–i) while pushing it with counterclockwise or slightly pulling it to enter the left coronary artery ostium (Fig. 14.4j).
Fig. 14.4
Coronary angiography of RCA was performed by MAC3.5 guiding catheter (a);slightly pull the catheter and let the MAC3.5 guiding catheter left ostium of RCA (b, c); push the catheter to form a big U shape (d–f); rotate the catheter clockwisely until its tip toward the left (g–i); push while counterclockwise or slightly withdraw the catheter to engage LCA with test injection (white arrow) (j)
14.5 Primay PCI Procedures in Luhe Hosptial
Algorithm routinely used for primary PCI in Luhe hospital see Fig. 14.5. For patients who are going to be performed primary PCI,after being given loading dose aspirin 300 mg and clopidogrel 600 mg or ticagrelor 180 mg,the patient was transferred to catheterization laboratory. Right radial artery with papable pulse was default access, if failed, switching to right or left femoral artery or left radial access. Heparin was the first choice for anticoagulation. In our catheterization laboratory, we routinely start with a 6 F MAC3.5 guiding catheter for coronary angiography and intervention. MAC 3.5 guide catheter is advanced into the aortic root over a standard 0.035-in., 1-mm, J-tipped guide wire. If any resistance is encountered during passage, dilute contrast should be injected via the guiding catheter to identify the problem (e.g., loop, spasm, cannulation of side-branch). If 0.035-in. wire fails then 0.035-in. hydrophilic wire or 0.14-in. guide wire can be used. An angiography of the non-infarcted artery should be performed first to allow identification of multivessel disease and collateral flow into the infarct zone with multiple projections. Angiography of the infarcted artery is performed with only limited projections to visualized the culprit lesion followed by using adjunctive techniques: non hydrophilic wire, aspiration catheter, balloon or stent.
Fig. 14.5
Suggested management algorithm for primary PCI in Luhe hospital. STEMI ST segment elevation myocardial infarction, DAPT dual antiplatelet therapy, RA radial artery, FA femoral artery, NIRA non infarct-related artery, IRA infarct-related artery, LCA left coronary artery, RCA right coronary artery, PCI percutaneous coronary intervention
14.6 Typical Cases Using a Single MAC Guiding Catheter for Primary PCI
Case 1
A 43-year-old male collapsed while walking on the way, around 8:00 am. When an ambulance arrived, the patient was unresponsive, pulseless, and not breathing. Cardiopulmonary resuscitation was started, and ventricular fibrillation was the initial rhythm recorded. Ventricular defibrillation (VF) was applied twice to terminate VF during resuscitation. After intubation, intravenous access was obtained, He was transferred to the Emergency Department for further resuscitation. Subsequent ECG revealed ST-segment elevation in leads I, II, V2–6 (Fig. 14.6). After administration of aspirin (300 mg) and ticagrelor (180 mg) via a nasogastric tube, he was transferred to the catheterization laboratory. Hemodynamic support was provided with dopamine and norepinephrine via the intravenous route. Coronary angiography was performed via the right radial artery using a 6 F single MAC3.5 guiding catheter (Medtronic, Inc., Minneapolis, MN, USA), based on the ECG, the RCA was the non-culprit vessel and firstly engaged, coronary angiography demonstrated normal RCA was dominant and normal. Left circumflex (LCx) was also normal as well as total occlusion of the mid-segment of the left anterior descending artery (LAD) (Fig. 14.7a). Two drug-eluting stents (3.5 × 30 mm and 3.5 × 15 mm) were implanted into the LAD (Fig. 14.7b), resulting in Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. Intra-aortic balloon pump (IABP) was inserted during the procedure. Consciousness was restored 3 days later. Impairment of short term memory was restored by hyperbaric oxygen therapy. The IABP was removed on day-2 and he underwent extubation on day-7. On day-21, he was discharged from hospital with prescriptions of aspirin, ticagrelor, a beta-blocker, a lipid-lowering drug, and an angiotensin-converting-enzyme inhibitor.
