Interventional Cardiology. Группа авторов

Figure 4.2 Guiding catheter selection for right coronary artery. (a) Normal: JR4. (b) Inferior orientation: modified right Amplatz. (c) Anterior origin (right cusp): Multipurpose. (d) Shepherd’s crook: Arani 75°, Champ. (e) Superior origin: MAC, Champ, Multipurpose. (f) Dilated root: AL2.

      Radial approach

The same curves suit most patients during left radial intervention, while a 0.5 downsizing of the left curve (e.g. to JL3.5 if JL4 would have been suitable from the femoral approach) is generally required when using the right arm. A Barbeau, Tiger, or Ikari catheter suitable for both the left and right coronaries can also be used from the right radial approach. Figure 4.3 shows Ikari catheters for radial approach

Figure 4.3 Ikari catheters for radial approach. (a) Ikari left. (b) Ikari right. Curve A to fit angle of brachiocephalic artery; straight portion B to generate strong back‐up force supported by opposite site of the aorta wall.

Coronary intubation

The left anterior oblique (LAO) view is most useful for intubation of the left and right coronary arteries, because the left and right coronary sinuses are maximally separated and there is minimal overlap between the ostia and the coronary sinuses (Figure 4.1). For intubation of the left system the J‐wire is advanced up to just above the aortic leaflets. The catheter is advanced over the wire and, when the tip nears the aortic sinuses, the J‐wire is withdrawn to allow it to come close to or intubate the coronary ostium. Slow J‐wire withdrawal is recommended to avoid the catheter tip flicking into the ostium which can cause dissection, plaque dislodgement, or spasm, and also to avoid sucking air into the proximal catheter hub. The right coronary is intubated by advancing the JR catheter over the J‐wire until the tip is just above the aortic leaflets. The wire is then partially withdrawn, often leaving it inside the distal catheter to facilitate manipulation. Taking and holding a deep breath can also help straightening proximal tortuosities, especially of the subclavian arteries when using a radial approach. Gentle counterclockwise rotation aiming the catheter tip toward the left with concomitant withdrawal is usually required. Gentle movements are emphasized to avoid sudden or deep intubation, which can precipitate spasm, and to avoid catheter kinking, especially using a radial approach. Before proceeding to inject dye the pressure trace is checked: if it is damped or ventricularized, there is the possibility of ostial right or LMS disease, spasm, complete occlusion of a non‐dominant RCA, or that the catheter tip is abutting the vessel wall. Forceful contrast injection during any of these scenarios could result in dissection or plaque dislodgement. Contrast injection with an occlusive catheter with contrast remaining at the end of the injection, for instance holding up into the conus branch, should also be avoided because this can precipitate ventricular fibrillation. Spasm can be reversed with intracoronary nitrate, for example isosorbide dinitrate (ISDN) 100–200 μg. Rapid but gentle catheter withdrawal is indicated until the coronary ostium is extubated or the pressure trace normalizes. A small dose of intracoronary nitrate can be required to counteract any coronary vasospasm (e.g. ISDN 100–500 μg depending on the blood pressure). On occasion, smaller (e.g. 5F or 4F) catheters are required to avoid damping caused by spasm in hyper‐reactive arteries or when there is ostial plaque.

      The active support offered by deep intubation is frequently used also during interventions. However, this technique presents several relative limitations. The obstruction of flow during deep cannulation can induce severe ischemia, not always prevented by the presence of side holes. There is a potential risk of air embolism because of aspiration of air (cavitation) while the wire is withdrawn if the catheter is damped inside the artery with a low back pressure. It is recommended to wait for backbleeding before connection of the angiographic catheter with the tubes, injecting saline or contrast only when the presence of air is fully excluded. Filling the catheter with contrast before intubation of the ostia also reduces the risk of coronary embolism and makes the catheters more visible at fluoroscopy. Injection of contrast before coronary intubation and repeated tests during cannulation should be avoided in patients with poor renal function. An effective way to confirm cannulation, usable by all the operators with an initial angioplasty experience, is to insert a wire into the proximal coronary arteries, a manoeuvre which is also helpful to stabilize the system during injection.

Diagnostic angiography

      Left‐sided views

The first view is chosen to identify LMS disease. Either a posteroanterior (PA) view with minimal angulation to the right to project the catheter tip off the spine or a caudal left anterior oblique (LAO, (the so‐called spider) view, are used most often. At least three to four perpendicular views are required to visualize the left coronary tree (Table 4.1 shows the most widely used combinations of views). In many patients these views would suffice, potentially even when proceeding immediately to angioplasty. However, because of variations in patient anatomy, such as increased overlap caused by prominent tortuosity, displacement, or rotation of the heart axis in the chest (e.g. when there is normal anatomic variation, chest wall deformity, previous cardiothoracic surgery, or lung pathology), modification of views or additional views are sometimes required. When a lesion is identified, additional views can be indicated depending on how well the affected coronary segment has been straightened and visualized (Table 4.2).

Table 4.1 Angiographic projections and optimal visualization of left and right coronary artery segments.

Coronary artery segment	LAO 40–50° Caudal 25–40° (spider)	AP RAO 5–15° Caudal 30°	RAO 30–45° Caudal 30–40°	AP/RAO 5–10° Cranial 35–45°	LAO 35–40° Cranial 25–35°	Lateral ± Caudocrania10–30°	l LAO 45–60°	RAO 30–45°
LM ostium	++	+	+	+++	+++	–	–	–
LM bifurc	+++	+++	++	–	–	–	–	–
LAD prox	++	++	+++	++	++	+	–	–
LAD mid	–	+