Comparison of standard versus radial artery–specific catheters, S Goel

1. Comparison of Standard versus
Radial artery specific catheters
Sunny Goel, MD
Maimonides Medical Center
Brooklyn, USA

2. Disclosures
• None

3. Introduction
• Most commonly used catheter for radial
artery catheterization are either standard
catheter i.e. Judkins Rt and Judkins Lt or the
radial artery specific catheters such as Tiger,
Jacky etc.
• The most commonly used single catheter is
Tiger catheter which can engage both Rt and
Lt coronary ostium without requiring an
exchange unlike the standard catheters

4. • The purpose of the study was to compare the
performance outcomes of the Judkins left and
Right catheter with the Tiger catheter in
patients undergoing coronary angiography via
transradial access

5. Methods
• Patient selection- A total 110 consecutive patients
who underwent coronary angiography at our
institution between March 2015 and April 2015
were enrolled in this study
• A written informed consent was obtained prior to
the procedure and block randomization method
was used to assign patients to either Judkins
catheter or the Tiger catheter in blocks of 4 [the
blocks were determined with a computer
algorithm written in SAS (Cary, NC)] to the two
intervention arms.

6. • The operators were notified of the catheter type
that the patient was randomized to.
• Inclusion criteria- All Patients undergoing an
elective diagnostic coronary angiography via
Transradial access were eligible for the study.
• Exclusion criteria- All patients with previous failed
attempts at transradial access, patients with prior
history of coronary artery bypass graft
(CABG), cardiogenic shock, an abnormal Allen’s
test, arterio-venous fistula or graft.

7. Radial artery cannulation
• All consented patients had a palpable radial artery pulse
and a positive modified Allen’s test to confirm patency of
both radial and ulnar arteries prior to the procedure
• The right radial approach was used in all patients.
• After local anesthesia with 0.5% lidocaine, the radial artery
was punctured using the Seldinger technique with a 22-
gauge needle, and a 6Fr X 16-cm sheath (Terumo
Cardiovascular, Somerset, NJ) was introduced over the wire.
• To prevent arterial spasm, 300 mg of nicardipine was
administered through the sheath followed by 2000 to 3000
units of Heparin

8. Coronary engagement and
angiography
• All procedures were performed by highly skilled and
experienced operators with an experience of over 200
transradial coronary angiography. All operators were
proficient with the use of both Judkins and Tiger
catheters.
• A 30-degree left anterior oblique or anteroposterior
projection was used for manipulating the catheters.
• A standard, fixed-core, 153-cm long, 3-mm, J-curve
0.035” guide-wire was used for the insertion and
exchange of catheters. With the guide wire positioned
in the aortic cusp, the catheters were advanced under
fluoroscopic guidance.

9. Judkins Engagement

10. • Although in our catheterization laboratory,
fluoroscopic guidance is generally not utilized
during the catheter exchange, there is a small
number of cases where fluoroscopic guidance
was used to confirm the position of the wire
which was excluded for the study purposes.
• The time used to perform the catheter
exchange was also excluded for study
purpose.

11. Tiger engagement

12. • In an event of failure to engage the coronary artery
ostium or suboptimal coronary angiography quality
with the use of tiger catheter, the patients were
crossed over to Judkins catheter.
• In an event of failure of Judkins catheter, the catheter
selection was left to the discretion of the operator.
• When the decision was made to a catheter exchange,
access site switch or PCI the study was stopped and the
outcomes were measured up to that point

13. Study end points
• Primary end points- (a) Fluoroscopy time (b)
Dose area product (DAP)(c) Contrast volume
and (d) Total procedure time
• Secondary end points- (a) Procedural success
(b) Technical success and (c) Access site switch

14. Statistical analysis
• We performed unadjusted comparison of
catheter performances
• Student t-test was used for comparing
continuous variables and the chi-square test
for comparing categorical variables
• A p value of <0.05 was considered as
statistically significant.
• Statistical Analysis was performed with the
SPSS, version 22.0 (Armonk, NY: IBM Corp).

15. Results
• A total of 57 (52%) patients were randomized
to radial artery specific catheter and 53 (48%)
patients to standard catheters.
• No statistically significant differences were
found in baseline characteristics between the
two groups

17. Results- Primary end points
• The primary end points of the study showed that Tiger
catheter have better performance outcomes.
• The patients who underwent coronary angiography using
Tiger catheter had significantly shorter total fluoroscopy
time (184.11+ 90.99 seconds versus 237.85+130.96
seconds, P=0.015) which was statistically significant.
• Other outcome measures DAP (2882.49+1471.23 versus
3524.51+2111.62, P= 0.07), total contrast volume
(48.16+16.11 versus 53.45+18.50 ml, P= 0.114) and total
procedure time (337.28+381.55 versus 434.22+136.67
seconds, P=0.085) were also lower in Tiger catheter group
but it did not reach statistical significance.

19. Results- Secondary outcomes
• There were no procedural or clinical complications with
either Tiger or Judkins catheter.
• A total of six patients had to be switched to femoral access
(3 in each group) secondary to radial artery spasm.
• A total of eight (14%) patients were crossed over from the
radial specific catheter arm to the standard catheters arm
because of substandard image quality and/or difficulty in
coronary engagement as determined by the operator
performing the procedure.
• Of these 8 patients, One (2%) case required a switch to left
Judkins Catheter, four (7%) cases required switch to right
Judkins catheter and three (5%) cases required switch to
both left and right Judkins.

21. Discussion
• We found a statistically significant reduction in
fluoroscopy time using the Tiger catheter compared
with standard Judkins catheter. The DAP, contrast
volume, and total procedure time were also lower for
Tiger catheter but did not reach statistical significance.
• These reductions with the single-catheter approach are
important findings in our study. For high-volume
centers, such as the one in which our study was
conducted, where multiple procedures are performed,
it can help reduce the cost of coronary angiograms,
improve the speed of procedures, and decrease the
amount of radiation exposure to the operators

22. • The increased procedure time using Judkins catheter
can be explained by the need to perform the catheter
exchange for the purpose of engaging the left and right
coronary arteries. This catheter exchange not only
prolongs the total procedure time but also increases
the patient discomfort.
• Another important observation in our study was the
rate of radial artery spasm. Tiger catheters are
traditionally considered superior to Judkins catheters
as they reduce radial artery spasm. However, in our
study, we found similar rates of spasm in both catheter
groups. The similar rates of spasm may be attributed to
the small sample size of our study population.

23. • The safety profiles of both catheters were similar, with
no reported complications.
• The Judkins catheter appeared to be superior in both
cannulation of coronary ostia and the quality of
angiographic imaging.
• However, because the failure rate of the single catheter
for both left and right coronaries was found to be so
low (5%), we find it reasonable to start with a single-
catheter approach and subsequently exchange for a
Judkins catheter when needed. This protocol can allow
for reduction in procedure time and total fluoroscopy
time.

24. Limitations
• Our sample size may have been insufficient to detect a statistically
significant reduction in contrast volume, procedure time, or the
DAP using radial artery specific catheter.
• Our study was also limited to the comparison of the standard
Judkins catheter to the Tiger catheter as it is the most commonly
used catheter in practice, although multiple catheter types exist.
Therefore, our findings cannot be generalized to include all single-
catheter approaches.
• Last, outcomes of studies, such as ours, are highly operator
dependent, which may vary among different interventionalists,
their experience with TRA, and their use of specific catheters. The
reported learning curve for the TRA is 30 to 50 cases per operator.
Although our study was not limited to a single operator, we did
include study operators who had the experience of performing at
least 200 TRA cases, with expertise in using both the standard
Judkins catheter and the Tiger catheter

25. Conclusion
• The radial artery specific catheter was shown
to have significantly lower fluoroscopy times
but higher failure rates compared with the
standard catheters.