|Year : 2020 | Volume
| Issue : 1 | Page : 78-80
Use of judkins left as a multipurpose catheter for simultaneous transradial percutaneous coronary angioplasty of left and right coronary arteries: A time-saving and cost-effective innovation
Naresh Gaur, Kunal Mahajan, Neeraj Ganju, Rajesh Sharma, Rao Somendra, Vaishali Verma, Ashu Gupta
Department of Cardiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Submission||03-Dec-2019|
|Date of Decision||21-Jan-2020|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||17-Apr-2020|
Department of Cardiology, Indira Gandhi Medical College, Room Number 310, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Proper hardware selection during percutaneous coronary angioplasty (PCI) remains the key to the successful procedure, especially in the setting of an acute coronary syndrome (ACS) where minimizing the procedure time and the amount of dye is of utmost importance. Recent studies have demonstrated the benefit of complete revascularization in cases of multivessel disease in the ACS setting. During transradial intervention in a case of multivessel PCI, guiding catheter-induced radial artery spasm is a major concern. People have used guiding catheters such as Ikari for simultaneous PCI of right and left coronary arteries. This minimizes the risk of radial spasm and saves precious time, especially in the setting of ACS where each second counts. Limited data exist regarding the use of Judkins left (JL) catheter for PCI of simultaneous right and left coronary artery. Here, we describe an interesting case of simultaneous PCI of left anterior descending – infarct-related artery and right coronary artery – chronic total occlusion through transradial route using JL guide catheter in the setting of ACS.
Keywords: Angioplasty, Judkins left, multipurpose catheter
|How to cite this article:|
Gaur N, Mahajan K, Ganju N, Sharma R, Somendra R, Verma V, Gupta A. Use of judkins left as a multipurpose catheter for simultaneous transradial percutaneous coronary angioplasty of left and right coronary arteries: A time-saving and cost-effective innovation. J Pract Cardiovasc Sci 2020;6:78-80
|How to cite this URL:|
Gaur N, Mahajan K, Ganju N, Sharma R, Somendra R, Verma V, Gupta A. Use of judkins left as a multipurpose catheter for simultaneous transradial percutaneous coronary angioplasty of left and right coronary arteries: A time-saving and cost-effective innovation. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Nov 26];6:78-80. Available from: https://www.j-pcs.org/text.asp?2020/6/1/78/282814
| Introduction|| |
Percutaneous coronary angioplasty (PCI) remains the preferable revascularization approach in patients with acute coronary syndrome (ACS). PCI in the setting of ACS through the femoral route still remains the priority for many intervention cardiologists as arterial access and subsequent procedure is probably less time consuming. In case of chronic total occlusion (CTO) also, femoral approach is the preferred route and proper guide catheter support is much-needed aspect for successful angioplasty. Overall, appropriate guide catheter selection according to the coronary anatomy and obstructive lesion morphology is paramount prerequisite.
With the advancement of hardware, the success of PCI has definitely increased. For example, availability of guide catheters such as Ikari as a multipurpose guiding catheter not only decreases procedural time and the amount of dye used but also increases the likelihood of a successful procedure. There are no universal guidelines on how to perform PCI; rather, the experience with different types of hardware and using them appropriately is the key to success. This is especially true in low-income countries where the cost of PCI is the limiting factor.
There are few case reports where angioplasty has been done using a Judkins left (JL) catheter for both right coronary artery (RCA) and right coronary artery (LCA). However, data regarding simultaneous RCA and LCA angioplasty using JL guide catheter in the setting of ACS where one of the lesion is a CTO are lacking.
| Case Report|| |
A 65-year-old female patient, nondiabetic and hypertensive, with a history of Class II angina for the past 6 months and resting anginal episodes for 1 week was admitted to our coronary care unit. She was managed as Non-ST elevation myocardial infarction (NSTEMI) since electrocardiogram showed ST-segment depression in anterior precordial leads and troponin-T was positive. The patient was taken for coronary angiography through right radial artery approach with the help of tiger catheter 5F, which showed total cutoff of RCA in its mid-segment [Figure 1] and left anterior descending (LAD) showed a tubular concentric lesion with maximum 90% stenosis in its proximal segment [Figure 2]. There were Grade II intercoronary collaterals to RCA up to the crux from LAD.
|Figure 2: A tubular lesion with maximum stenosis of 90% in proximal left anterior descending.|
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The patient was subjected to angioplasty using a single guide catheter JL 3.5 6F. First, we hooked RCA and tried to cross the lesion with balanced middleweight (BMW) wire but could not. Then, we have tried with Gaia II wire and took left radial artery access through anatomical snuff box to look for retrograde RCA collaterals from left coronary artery (LCA) injections. This helped us to direct the Gaia wire toward the RCA crux. Finally, we were able to cross the lesion with the same wire [Figure 3]. Subsequently, multiple tandem dilatations were given with a 1.25 mm × 10 mm balloon followed by a larger balloon (2.0 mm × 10 mm). Good antegrade flow was achieved. The lesion was then stented with a 3.5 mm × 48 mm drug-eluting stent [Figure 4] followed by postdilatation with a 3.5 mm × 15 mm noncompliant balloon. There was no residual stenosis [Figure 5]. Then, with the help of the same guide catheter JL 3.5 6F, LCA was hooked, and BMW wire was passed across the LAD lesion and direct stenting was done in the proximal LAD with 3.0 mm × 24 mm drug-eluting stent [Figure 6] and [Figure 7]. There were no procedure-related complications. The patient remained asymptomatic during hospitalization and discharged without any complication.
|Figure 3: Lesion in the right coronary artery crossed with Gaia wire. Note that retrograde injection from the left five coronary arteries was used to guide the progress of wire.|
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| Discussion|| |
For successful coronary angioplasty, appropriate guide selection is of paramount importance, especially while performing transradial intervention. There should be good backup support, coaxial cannulation, and stability. Various types of guiding catheters have been described according to the anatomy of the coronary artery including the anomalously originating arteries. For example, RCA angioplasty using JL guide catheter has been described for anomalous RCA originating from the left coronary sinus. However, the use of JL for the normal origin of RCA intervention is rarely described. In a prospective study, 6Fr Ikari left (3.5) guiding catheter was used for simultaneous LCA (LAD or LCX) and RCA angioplasty. An Indian author has previously described that when the secondary curve of the JL catheter is straightened with Teflon guidewire, it behaves like a JR catheter and can be used for RCA lesions. It was hypothesized that the secondary curve of the JL guide catheter provides extra support for RCA lesions, especially in shepherd crook RCA. Moreover, JL is less traumatic than amplatz left (AL) for such an indication.
Although there are other multipurpose guide catheters (Kimney, Fadajet, and Barbeau catheters), their availability is a major concern. JL is an easily available catheter and can be used for multivessel PCI.
| Conclusion|| |
JL guide catheter can be used as a multipurpose guide for simultaneous RCA and LCA PCI, especially in low-income countries where limited resources are the commonly encountered scenario. This approach is useful since it prevents the catheter-induced radial artery spasm and minimizes the procedure time, dye load, and procedural complications. All these benefits are of paramount importance, especially in the ACS setting where each second counts.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]