CATHETERS,WIRES & OTHER DEVICES IN IRDr.Saurabh Joshi, MD, FNVIR

Sven Ivar Seldinger

Simple 18 guage angiographic puncture needle - one-piece open needle with a sharp beveled tip. guidewire is introduced directly through the needle once the tip is fully within the bleeding vessel lumen. This style of needle can be used for both arterial and venous punctures.

Balkin’s Cross over sheathPlaced on contralateral side after crossing over the aortic bifurcation.Facilitates easy access and treatment to lesions in the Iliac / SFA and high tibial arteries.

• Vascular sheath : Placed over the wire, through the access site. open at one end and capped with a hemostatic valve at the other. Walls are non tapered – beveled to closely match the dilator size so as to give a smooth transition between sheath and dilator. Available in various lengths and diameters. Diameter of a sheath is measured in “French”. Sheath selection is based on intended purpose

• Short 4 / 5 Fr sheaths for diagnostic purposes. Long sheaths with larger diameters for interventions.

• Common guidewires. Left to right,Straight 0.038-inch; J-tipped 0.038-inch with introducer device (arrow) to straighten guidewire during insertion into needle hub; angled high-torque 0.035-inch; angled hydrophilic-coated 0.038-inch nitinol wire with pinvise(curved arrow) for fine control; 0.018-inch platinum-tipped microwire.

Click icon to add pictureBasic construction of common guidewires. 

1 and 2, Curved and straight safety guidewires with outer coiled spring wrap, central stiffening mandril welded at back end only, and small safety wire (arrow) welded on inside at both ends. 

3, Movable-core guidewire in which mandril can be slid back and forth and even removed completely to change wire stiffness, using handle incorporated into guidewire (arrow). 

4, Mandril guidewire in which soft spring wrap is limited to one end of guidewire (arrow). Remainder of guidewire is a plain mandril. 5, Mandril guidewire coated with hydrophilic substance (arrow).

Click icon to add picture• Guidewires are available in a number of thicknesses, lengths, tip

configurations, stiffnesses, and materials of construction.

• Guidewire - the same as or slightly smaller than the diameter of the lumen at the tip of the catheter or device that will slide over it.

• Too big will jam, usually at the tip of the catheter.

• If a guidewire is much smaller than the end hole of the catheter or device, there will be a gap between the guidewire and catheter that can cause vessel injury or prevent smooth movement over the guidewire.

• Thickness measured in one hundrethds of an inch : 0.038 Inches,0.035 inches, 0.014 inches etc.

CATHETERS

• Common catheter shapes. 1, Straight; 2,Davis (short angled tip); 3, multipurpose (“hockey-stick”); 4, headhunter (H1); 5,cobra-2 (cobra-1 has tighter curve, cobra-3 has larger and longer curve); 6,Rösch celiac; 7, visceral (very similar to Simmons 1); 8, Mickelson; 9, Simmons-2;10, pigtail; 11, tennis racket.

Flush catheters

• Allow high-flow injections into the aorta or inferior vena cava.

• Uniform dispersal (with minimal recoil) of contrast media via multiple side holes.

• The tip is usually designed to help center the shaft in the vessel and prevent engagement and injection into a branch vessel.

Selective catheters

• Have rotational stiffness to seek a vessel orifice, but with enough flexibility to pass the catheter far into the vessel.

• Shaped in a particular way to seek intended vessel ostium.

• Catheter outer size is described in French gauge (3F = 1 mm).

• Diameter of the end hole (and therefore the maximum size of the guidewire the catheter will accommodate) is described in hundredths of an inch.

• The length of the catheter is described in centimeters (usually between 65 and 100 cm).

• The shape of the tip is named for either something the catheter looks like (“pigtail,” “cobra,” “hockey stick”), the person who designed it (Simmons, Berenstein, Rösch), or the intended use (celiac, left gastric, “head-hunter”)

COMPLEX CATHETERS

• Complex catheter shapes must be re-formed inside the body after insertion over a guidewire.

• Any catheter will resume its original shape, provided there is sufficient space within the vessel lumen and memory in the catheter material.

• Some catheter shapes cannot re-form spontaneously in a blood vessel, particularly the larger recurved designs like the Simmons.

• Aortic spin technique for re-forming a Simmons catheter (works best for Simmons 1). 1, Catheter is simultaneously twisted and advanced in proximal descending thoracic aorta. 

SELECTIVE CATHETERIZATION

Click icon to add picture

Choosing a selective catheter shape:

 A,Angled catheter when angle of axis of branch vessel from aortic axis is low.

 B,Curved catheter (e.g., cobra-2, celiac) when angle of axis of branch vessel is between 60 and 120 degrees. 

C,Recurved catheter (e.g., SOS, Simmons) when angle of axis of branch vessel from aorta is great.

How to use a cobra catheter:

1. Catheter advanced to position proximal to branch over guidewire, then pulled down(arrow). 

2. Catheter tip engages orifice of branch. Gentle injection of contrast agent to confirmed location. 

3. Soft-tipped selective guidewire has been advanced into branch.

4. Guidewire is held firmly, and catheter is advanced.

5. Catheter in selective position.

How to use a Simmons catheter:

1. Catheter is positioned above branch vessel with at least 1 cm of floppy straight guidewire beyond catheter tip. 

2. Catheter is gently pulled down (arrow)until guidewire and tip engage orifice of branch. 

3. Continued gentle traction results in deeper placement of catheter tip.

4. To deselect branch, push catheter back into aorta (reverse steps 1-3).

MICROCATHETERS• Small catheters (3F or smaller outer

diameter) that are specially designed to fit coaxially within the lumen of a standard angiographic catheter are termed microcatheters.

• Typically 2F to 3F in diameter, with 0.010- to 0.027-inch inner lumens.

• Designed to reach far beyond standard catheters in small or tortuous vessels.

• Wide range of characteristics:

1. stiffness,

2. braiding,

3. flow rates,

4. hydrophilic coatings.

Progreat MicrocatheterThis is a commonly used microcatheter in perpheral vasculature used to facilitate embolization of Bronchial arteries, GI bleeds, Uterine Fibroid embolization etc.This microcatheter allows embolization with microparticles as well as 0.018 coils.

Exelcior SL 10Echelon 90 *

These are microcatheters commonly used in embolization of intracranialAneurysms.

• When using a microcatheter, a standard angiographic catheter that accepts a 0.038- or 0.035-inch guidewire is first placed securely in a proximal position in the blood vessel.

• The microcatheter is then inserted through the outer catheter and advanced in conjunction with a specially designed 0.010- to 0.025-inch guidewire through the standard catheter lumen.

• Once a superselective position has been attained with the microcatheter, a variety of procedures can be performed, including embolization, sampling, or low-volume angiography.

GUIDING CATHETERS

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• Designed to make selective catheterization and interventions easier.

• These catheters can be used in some situations to help position and stabilize standard catheters.

• These catheters can be used in some situations to help position and stabilize standard catheters.

• They are used in circumstances in which standard catheters are difficult to position selectively. 

Guiding CatheterThese are large lumen catheters that are placed proximal to give stable position for placement of instruments like microcatheters, coils, stents within target lesion.

Y ConnectorThese are connected on the hub of guiding catheters for haemostasis and for placement Of microcatheters as well as allow a continuous infusion of heparinized saline from the side port.

Angioplasty Balloon

Shaft length , wire compatibilty, sheath compatibilityRadio opaque markersSizingMax atm pressure

Principle of Angioplasty :

Plaque FractureIntimal TearingMedial Stretching

Self Expanding StentHave radial force that anchors stent to target vessel as it deploys.Can be made of Nitinol that has thermal memory, they reach full expansion at normal body temperature. Nickel titanium alloy.

Balloon Mounted StentMounted over a balloon, expansion of the balloon Causes deployment of this type of stent.Precise positioning is required and is more rigid.These are not placed over joints as can fractue.

Stent-grafts represent a combination of stent and surgical bypass conduit technology. Internal bypasses.

Embolic Protection Devices

Atherectomy Device

Biliary Internal – External DrainThis has proximal as well as distal drainage holes that allow drainage of bile proximal to lesion externaly.If the drain is internalised, that is the lesion is crossed and distal end is placed in the duodenum then bile is drained via the proximal holes into the Duodenum via distal holes.

Chiba NeedleUsed to gain access to bilary ducts.This can be done under Fluoroscopic Or USG guidance.

Trapease Filter Greenfield filter

Used to prevent pulmonary embolism in patients with DVT in whom long term anticoagulant therapy is contraindicated. Commonly placed in infrarenal IVC after confirming negative jet of renal veins.Can be permanent or temporary. Temporary filters have to be removed within 6 weeks to prevent endothelization of the filter.

EMBOLIZATION AGENTSDr.Saurabh Joshi, MD, FNVIR

“

”DELIBERATE OCCLUSION OF A BLOOD VESSEL TO ACHIEVE A THERAPEUTIC RESULT

Treatment of tumors

Varicosities

Vascular malformatio

ns

Aneurysms and pseudoaneurys

ms

Technique has evolved to include nearly every vascular territory and has been used in such diverse clinical applications as :

DEVICE SELECTION

vascular territory to

be embolized

permanence of occlusion

degree of occlusion—proximal or

distal—desired

PERMANENT LARGE-VESSEL OCCLUSIONS

Coils Balloons

Amplatz Vascular

Plug

Guidewires

PERMANENT SMALL-VESSEL OCCLUSIONS

ParticlesLiquid

sclerosants

Liquid adhesive

Ethiodol

TEMPORARY LARGE-VESSEL OCCLUSIONS

Gelfoam sponge

Autologous clot

TEMPORARY SMALL-VESSEL OCCLUSIONS

Gelfoam powder

Starch microsphere

s

Fibrillated collagen

GENERAL EMBOLIZATION SCHEME AND CLINICAL INDICATIONS

Permanent Temporary

Large vesselCoils (e.g., pulmonary AVM)

Gelfoam sponge (e.g., trauma)

Small vessel

Particles (e.g., UFE); no organ deathLiquid agents (e.g., renal ablation); organ death

Gelfoam particles, fibrillated collagen (e.g., chemoembolization)

AUTOLOGUS CLOT :

Avantages : immediate availability, absence of cost, and lack of adverse reaction.

Method : aspirate roughly 20 mL of the patient's blood and allow it to clot, then discard the supernatant and reintroduce the clot through the catheter. If desired, the clot can be opacified by adding sterile tantalum powder.

Drawback : Rapid lysis time, which can lead to recanalization within 6 to 12 hours. This problem can be partially overcome by modification of the autologous clot.

If a very proximal occlusion is desired, Gelfoam "torpedoes" can be formed by compressing and rolling strips of Gelfoam, which are then loaded into the nozzle of a 1- or 3-mL syringe.

Gelfoam Pledgets Gelfoam Torpedo

For more distal embolization, a slurry of Gelfoam can be created by macerating the pledgets with two syringes and a three-way stopcock: the more passes the Gelfoam makes through the stopcock, the more it is fragmented and the smaller the pieces become.

Gelfoam embolization provides a temporary occlusion lasting approximately 3 to 6 weeks.

Used for embolization of pelvic trauma or postpartum hemorrhage, especially when there are multiple punctuate bleeding sites from various branches of the internal iliac artery. In such situations, embolization should be initiated with Gelfoam slurry to achieve a relatively distal level of occlusion and then followed by Gelfoam pledgets or torpedoes.

PVA ParticlesUsed in bronchial artery embolization,

Uterine fibroid embolization etc.

• Polyvinyl alcohol (PVA) is essentially a plastic sponge that is fragmented and then filtered to a certain size range.

• PVA is available in sizes between 50 and 2000 µm, the typical size ranges used clinically are 300 to 500 µm or 500 to 700 µm.

• Smaller particles have a significant risk of tissue infarction due to their distal level of occlusion. Larger particles may occlude the delivery catheter

USES

• Predominantly for tumor embolization, either for preoperative devascularization or as definitive treatment, such as in uterine fibroid embolization, JNA embolization. 

• PVA can be used when treating hemorrhage of a vascular bed with multiple small branches eg. hemoptysis in patients with chronic inflammatory lung disease.

• Prior to bronchial embolization, the presence of a spinal artery originating from the treated vessel should be excluded.

OTHER PARTICULATE AGENTS :

• Microspheres (Embosphere, BioSphere Medical, Rockland, MA).

• Embospheres are precisely calibrated, spherical, hydrophilic, microporous beads made of an acrylic copolymer, which is then cross-linked with gelatin.

• The hydrophilic surface prevents aggregation, allowing a more predictable, uniform vessel occlusion than PVA, as well as easier delivery through small catheters.

• SIR Spheres : Ceramic microspheres have been embedded with the beta emitter Yttrium-90.  Provide internal radiation of hepatic malignancies

Pre and Post Uterine Fibroid Embolization

USE OF PVA PARTICLES

EMBO CASE

• 11 yr old male child presented with recurrent nasal obstruction and epistaxis since 2 months.

• ENT examination showed mass in the left nasopharynx.

• CT was done.

1. STA

2. LA

3. FA

4. OA

5. APA

6. PAA

7. STA

8. IMAX

9. MMA

ECA EMBOLIZATION ..

Are there collaterals between ECA – ICA – VB circulations ?

Extra cranial Intracranial

Major artery Location Branch Branch Artery

Internal maxillary artery

Proximal MMAOrbital branches, anterior branch (anterior falcine artery)

Ophthalmic artery

Cavernous branches ILT

Petrous branch CN VII supply

Proximal AMAArtery of foramen ovale

ILT

Distal Vidian artery Petrous ICA

DistalArtery of foramen rotundum

ILT

DistalAnterior deep temporal artery

Ophthalmic artery

Superficial temporal artery

Frontal branch Supraorbital branch Ophthalmic artery

Ascending pharyngeal artery

Pharyngeal trunkSuperior pharyngeal artery

Carotid branch (foramen lacerum)

Lateral clival artery

Neuromeningeal trunk Odontoid arch Vertebral artery (C1)

Hypoglossal and jugular branch

Meningohypophyseal trunk of ICA

Posterior auricular-occiptal artery

Stylomastoid branch CN VII supply

Occipital artery Muscular branchesVertebral artery (C1–C2)

Ascending and deep cervical arteries

Vertebral artery (C3–C7)

Summary of the major extra- and intracranial anastomoses•Note:—MMA indicates middle meningeal artery; AMA, accessory meningeal artery; ILT, inferolateral trunk; ICA, internal carotid artery; CN, cranial nerve.

Diagram of the functional vascular anatomy of the head and neck with the 3 major extracranial–intracranial anastomotic pathway regions: the orbital, petrous-cavernous-clival, and upper cervical regions.

Geibprasert S et al. AJNR Am J Neuroradiol 2009;30:1459-1468

©2009 by American Society of Neuroradiology

Detachable CoilsUsed in Intracranial AneurysmCoiling.

Pushable Coils Used in Peripheral Embolization.

COILS

•  First embolic coils consisted of pieces of stainless steel guidewires onto which strands of wool had been woven to add a matrix for thrombus formation.

• Stainless-steel coils are best suited for high-flow applications due to their high radial force, which helps prevent dislodging.

• Platinum coils are highly visible under fluoroscopy and are much softer than stainless steel. This facilitates accommodation of the coil to the vessel.

• Appropriate sizing is important to ensure occlusion of the vessel at the intended location.

•  Gugliemi detachable coil : Coil is welded to the pusher wire in the desired position, the wire is attached to a battery device that sends a current along the wire. The current melts the welded connection between the coil and the wire and detaches the coil without any force. GDCs are mainly used for treatment of intracranial aneurysms.

USES

• Embolization with coils produces a focal occlusion, leaving the vessel distal to the coil patent, similar to surgical ligature. Therefore, coils are utilized in almost any application in which precise vessel occlusion--but not tissue ablation--is necessary.

• Applications for coil embolization include treatment of hemorrhage, occlusion of arteriovenous fistulas,  and preoperative or pre-stent graft vessel occlusion. 

COIL EMBOLIZATION27 yr old female patient with secondary PPH

Taken up for Uterine Artery Embolization.

Pre-Procedure Angiogram Shows :

04/12/2023

66

Bilateral uterine arteries were embolised using pushable coils. There was no further bleeding.Patient was stable.

45 yr old female. Known diabetic. History of right thigh injury with soft tissue necrosis and continuous bleeding. Hb falling by 3 gms a day. Angiogram showed :

ENDOVASCULAR COILING OF INTRACRANIAL ANEURYSMS

LIQUID - POLYMERS

• Onyx : Liquid embolic agent, consisting of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx, Micro Therapeutics Inc., Irvine, CA).

• Onyx contains tantalum powder to render it radiopaque. After Onyx is injected into the target lesion, the dimethyl sulfoxide solvent rapidly diffuses away, causing precipitation of the polymer and formation of a spongy cast.

• The cast solidifies from the outside in. Onyx allows a prolonged, controlled embolization because of its nonadhesive nature.

• Used mainly in Cerebral and Peripheral AVM emboization

OnyxUsed for embolization of Cerebral AVMs,

Peripheral AVMs.

GLUE + LIPIDIOL

• n butyl cyanoacrylate.

• This agent is a permanent rapidly acting liquid, similar to glues sold under trade names such as "SuperGlue," that will polymerize immediately upon contact with ions. It also undergoes an exothermic reaction which destroys the vessel wall. Since the polymerization is so rapid, it requires a skilled surgeon. During the procedure, the surgeon must flush the catheter before and after injecting the NBCA, or the agent will polymerize within the catheter. The catheter must also be withdrawn quickly or it will stick to the vessel. Oil can be mixed with NBCA to slow the rate of polymerization.

• ethiodol - Made from iodine and poppyseed oil, this is a highly viscous agent. It is usually used for chemoembolizations, especially for hepatomas, since these tumors absorb iodine. The half life is five days, so it only temporarily embolizes vessels.

SCLEROSING AGENTS

• Cause protein denaturation, leading to endothelial destruction and vascular occlusion. Occlusion by sclerosants is usually permanent.

• Sodium tetradecyl sulfate (Setrol) and Polidocanol

• Uses : ablation of tumors, solid organs, veins, or vascular malformations.

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