Instrumentation: Working Chain

  • Panagiotis Xaplanteris
  • Guy R. HeyndrickxEmail author


The catheterization of coronary arteries for diagnostic or therapeutic reasons is accomplished by establishing a working chain of several consecutive and related steps, all of which can be hampered by technical difficulties. This working chain stretches from establishing the access site up to navigation of the coronary target site, all of which can become a source of problems. This chapter presents scenarios that are frequently encountered by interventional cardiologists in clinical practice, as well as techniques to overcome such challenging situations. Issues related to radial access, poor guidewire support, and access to difficult side branches are also covered. Moreover, owing to the increasingly complex nature of intracoronary interventions, combined use of devices is common. Therefore, pros and cons of smaller versus larger guiding catheters, the diameters of commonly used intravascular devices, and their compatibility are discussed and presented in tables. In addition, figures illustrating the mechanics of backup forces acting on catheters, common anatomic variations, and the integrated use of intracoronary devices for delivering devices are reviewed.


  1. 1.
    Lanzer P, Prechelt L. Expanding the base for teaching of percutaneous coronary interventions: the explicit approach. Catheter Cardiovasc Interv. 2011;77:372–80.CrossRefPubMedGoogle Scholar
  2. 2.
    Ikari Y. Slender transradial intervention. In: Nguyen T, Hu D, Chen SL, Kim M-H, Saito S, Grines C, Gibson CM, Bailey SR, editors. Practical handbook of advanced interventional cardiology. 4th ed. Oxford: Blackwell Publishing Ltd; 2012.Google Scholar
  3. 3.
    Sones FM Jr, Shirey EK. Cine coronary arteriography. Mod Concepts Cardiovasc Dis. 1962;31:735–8.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Balaji N, Shah PB. Radial artery catheterization. Circulation 2011;124: e407–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Valgimigli M, Gagnor A, Calabro P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385:2465–76.CrossRefPubMedGoogle Scholar
  7. 7.
    Ferrante G, Rao SV, Juni P, et al. Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials. JACC Cardiovasc Interv. 2016;9:1419–34.CrossRefPubMedGoogle Scholar
  8. 8.
    Hamon M, Pristipino C, Di Mario C, et al. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. EuroIntervention. 2013;8:1242–51.CrossRefPubMedGoogle Scholar
  9. 9.
    European Stroke O, Tendera M, Aboyans V, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2851–906.CrossRefGoogle Scholar
  10. 10.
    Pristipino C, Trani C, Nazzaro MS, et al. Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study. Heart. 2009;95:476–82.CrossRefPubMedGoogle Scholar
  11. 11.
    Rathore S, Stables RH, Pauriah M, et al. Impact of length and hydrophilic coating of the introducer sheath on radial artery spasm during transradial coronary intervention: a randomized study. JACC Cardiovasc Interv. 2010;3:475–83.CrossRefPubMedGoogle Scholar
  12. 12.
    Dahm JB, Vogelgesang D, Hummel A, Staudt A, Volzke H, Felix SB. A randomized trial of 5 vs. 6 French transradial percutaneous coronary interventions. Catheter Cardiovasc Interv. 2002;57:172–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Jia DA, Zhou YJ, Shi DM, et al. Incidence and predictors of radial artery spasm during transradial coronary angiography and intervention. Chin Med J. 2010;123:843–7.PubMedGoogle Scholar
  14. 14.
    Kwok CS, Rashid M, Fraser D, Nolan J, Mamas M. Intra-arterial vasodilators to prevent radial artery spasm: a systematic review and pooled analysis of clinical studies. Cardiovasc Revasc Med. 2015;16:484–90.CrossRefPubMedGoogle Scholar
  15. 15.
    Aminian A, Dolatabadi D, Lefebvre P, et al. Initial experience with the Glidesheath Slender for transradial coronary angiography and intervention: a feasibility study with prospective radial ultrasound follow-up. Catheter Cardiovasc Interv. 2014;84:436–42.CrossRefPubMedGoogle Scholar
  16. 16.
    Singh V, et al. Crossover from radial to ipsilateral ulnar access: an additional strategy in the armamentarium of the “Radialist”. Cath Lab Digest. 2015;23(4):30.Google Scholar
  17. 17.
    Jelev L, et al. Radial artery coursing behind the biceps brachii tendon: significance for the transradial catheterization and a clinically oriented classification of the radial artery variations. Cardiovasc Intervent Radiol. 2008;31(5):1008–12.CrossRefPubMedGoogle Scholar
  18. 18.
    Janssen M, et al. Dysphagia lusoria: clinical aspects, manometric findings, diagnosis, and therapy. Am J Gastroenterol. 2000;95:1411–6. Scholar
  19. 19.
    Patel T, Shah S, Pancholy S, Rao S, Bertrand OF, Kwan T. Balloon-assisted tracking: a must-know technique to overcome difficult anatomy during transradial approach. Catheter Cardiovasc Interv. 2014;83:211–20.CrossRefPubMedGoogle Scholar
  20. 20.
    Ikari Y, Nagaoka M, Kim JY, Morino Y, Tanabe T. The physics of guiding catheters for the left coronary artery in transfemoral and transradial interventions. J Invasive Cardiol. 2005;17:636–41.PubMedGoogle Scholar
  21. 21.
    Ikari Y, Nakajima H, Iijima R, et al. Initial characterization of Ikari guide catheter for transradial coronary intervention. J Invasive Cardiol. 2004;16:65–8.PubMedGoogle Scholar
  22. 22.
    Youssef AA, Hsieh YK, Cheng CI, Wu CJ. A single transradial guiding catheter for right and left coronary angiography and intervention. EuroIntervention. 2008;3:475–81.CrossRefPubMedGoogle Scholar
  23. 23.
    Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the ratio between radial artery inner diameter and sheath outer diameter on radial artery flow after transradial coronary intervention. Catheter Cardiovasc Interv. 1999;46:173–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Mamas M, D'Souza S, Hendry C, et al. Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: a feasibility study. Catheter Cardiovasc Interv. 2010;75:596–602.PubMedGoogle Scholar
  25. 25.
    From AM, et al. Sheathless transradial intervention using standard guide catheters. Catheter Cardiovasc Interv. 2010;76:911–6. stent is delivered through the child catheter (B). Final result after withdrawal of the childCrossRefPubMedGoogle Scholar
  26. 26.
    Bagnall AJ, Spratt JC. The “buddy-in-jail” technique—a novel method for increasing support during percutaneous coronary intervention. Catheter Cardiovasc Interv. 2009;74:564–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during advancement of a balloon in coronary angioplasty: the anchor technique. Catheter Cardiovasc Interv. 2003;59:482–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Hirokami M, Saito S, Muto H. Anchoring technique to improve guiding catheter support in coronary angioplasty of chronic total occlusions. Catheter Cardiovasc Interv. 2006;67:366–71.CrossRefPubMedGoogle Scholar
  29. 29.
    Aeby G, Surmely JF, Togni M, Cook S. A modified technique of balloon anchoring for tricky stent delivery. EuroIntervention. 2013;8:1099–102.CrossRefPubMedGoogle Scholar
  30. 30.
    Kohno H, Sueda S, Nakamura S. Effective use of the balloon-deflection technique for severely angulated bifurcation lesions: a case report. J Invasive Cardiol. 2010;22:E141–3.PubMedGoogle Scholar
  31. 31.
    Aranzulla TC, Sangiorgi GM, Bartorelli A, et al. Use of the venture wire control catheter to access complex coronary lesions: how to turn procedural failure into success. EuroIntervention. 2008;4:277–84.CrossRefPubMedGoogle Scholar
  32. 32.
    McClure SJ, Wahr DW, Webb JG. Venture wire control catheter. Catheter Cardiovasc Interv. 2005;66:346–50.CrossRefPubMedGoogle Scholar
  33. 33.
    Kawasaki T, Koga H, Serikawa T. New bifurcation guidewire technique: a reversed guidewire technique for extremely angulated bifurcation—a case report. Catheter Cardiovasc Interv. 2008;71:73–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Mylotte D, Routledge H, Harb T, et al. Provisional side branch-stenting for coronary bifurcation lesions: evidence of improving procedural and clinical outcomes with contemporary techniques. Catheter Cardiovasc Interv. 2013;82:E437–45.PubMedGoogle Scholar
  35. 35.
    Murray CD. The physiological principle of minimum work: I. The vascular system and the cost of blood volume. Proc Natl Acad Sci U S A. 1926;12:207–14.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Finet G, Gilard M, Perrenot B, et al. Fractal geometry of arterial coronary bifurcations: a quantitative coronary angiography and intravascular ultrasound analysis. EuroIntervention. 2008;3:490–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiovascular Center AalstOLV-ClinicAalstBelgium

Personalised recommendations