Efficacy of a one-catheter concept for transradial coronary angiography
Efficacy of a one-catheter concept for transradial coronary angiography
Christoph Langer 0 1
Julia Riehle 0 1
Helge Wuttig 0
Stephanie DuÈ rrwald 0
Helmut Lange 0
Alexander Samol 0
Norbert Frey 0 1
Marcus Wiemer 0
0 Editor: Rajesh Gopalrao Katare, University of Otago , NEW ZEALAND
1 Klinik fuÈ r Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Universit aÈtsklinikum Schleswig-Holstein , Campus Kiel, Christian-Albrechts-UniversitaÈ t Kiel, Kiel, Germany, 2 Kardiologische-Angiologische Praxis±Herzzentrum Bremen, Bremen, Germany , 3 Klinik fuÈ r Kardiologie und Internistische Intensivmedizin, Johannes-Wesling-Klinikum Minden, UniversitaÈtsklinikum der Ruhr-Universit aÈt BochumHans-Nolte-Straûe 1 , Minden , Germany
The Tiger employed as a single catheter in TRC is an effective tool to achieve lower contrast
volume and fluoroscopy time at a low complication rate. Unstable engagement affects
predominantly the left coronary artery, but its overall frequency is similar for both, the Tiger and
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
Transradial coronary angiography (TRC) and PCI were introduced by Campeau in 1989 [
and Kiemeneij in 1992 [
]. The use of TRC has risen significantly due to its lower risk of
bleeding and earlier postprocedural ambulation, especially for the high risk group of the elderly [
]. According to current guidelines it is the recommended access in STEMI [
Difficult advancement of the catheter through tortuous and sometimes spastic arteries in
the right arm and neck is an important disadvantage of TRC resulting in increased radiation
exposure of the patient and the operator [
]. This led to the one-catheter-concept: a
uniquely designed catheter which can be engaged in either coronary ostium [10±12]. It avoids
any catheter exchange, thereby protecting upper limb vessels from repeated mechanical
irritation and resulting in lower procedure and fluoroscopy times and lower cost. However, despite
these advantages [
] many operators, including very experienced ones, reported difficulties
maintaining a stable position within the coronary ostia during dye injection often resulting in
disengagement of the catheter.
In the present registry of two centers favoring TRC, we investigated the
one-catheter-concept of the widely used catheter ªTigerº (ªTiger IIº; TerumoTM) [
] by comparing catheter
stability during contrast injection, contrast volume, fluoroscopy time (FT) and complication
rate of the Tiger catheter to the Judkins catheters.
Material and methods
This project has been registered and approved by the local ethics committees at the University
Medical Centre Schleswig-Holstein in Kiel and at the Johannes-Wesling-Klinikum (University
Medical Centre of the Ruhr-University Bochum) in Minden, Germany. All patients had given
written informed consent prior to any data acquisition.
In this dual centre registry we identified all diagnostic TRC procedures performed at the two
participating catheterization laboratories in 2012 and 2013 [
]. All procedures were
performed in a standard fashion from the right radial artery using 4F, 5F or 6F sheaths
(TerumoTM). In both centers the Tiger is by far the most frequently used catheter for TRC (standard
catheter). However, whether or not to use a Tiger or conventional catheters, was left to the
discretion of the operator. For the one-catheter approach the Tiger 4 curve was primarily chosen
in patients presenting with a body length of 175cm, 3.5 curve in case of <175cm. For the
conventional approach Judkins left 3.5 and Judkins right 4 curves were used. Cases with acute
coronary syndromes and cardiogenic shock were included. Excluded from the analysis were
cases done by low volume operators, defined as < 80 TRC procedures per year, procedures
with bypass graft angiography, primary left radial approach, procedures performed under the
use of other diagnostic caths than the Tiger or Judkins catheters, and those with a planned or
ad hoc PCI. In the exclusively evaluated diagnostic TRCs fluoroscopy time (taken during 8
cine angiography standard projections) and contrast volume (given by hand in all cases) were
taken from catheterization reports. Charts and discharge summaries were searched for
Coronary angiograms (demonstrating stability of the catheter during contrast injection)
were evaluated at both institutions by one and the same independent observer not involved in
Stability was judged to be good if no disengagement was noted during injection of contrast
into either left or right coronary artery (ª0º was registered for stable). Poor ostial stability was
defined as disengagement from the left coronary ostium (LCO) or the right coronary ostium
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(RCO) once or more than once during cinematography leading to semi-selective contrast
injection and incomplete filling of the coronary artery (ª1º was registered for unstable).
Failure of the Tiger catheter was defined as inability to achieve satisfactory catheter
engagement from the right radial artery necessitating the use of a Judkins-type catheter or change of
vascular access to the contralateral radial or femoral artery.
Statistical analysis was performed by the Institute of Medical Biometrics and Statistics of the
Christian-Albrecht-University of Kiel, Germany applying the SPSS Statistics software (Version
21; SPSS Inc.; Chicago, Illinois). Continous data was expressed as mean value and standard
deviation. All data was scanned whether normally distributed data. In case of not normal
distribution the Wilcoxon signed rank test was performed. A two-tailed p value <0.05 was
The entire study cohort from both centers consisted of n = 2953 consecutive TRC procedures.
Exclusion according to the study criteria resulted in 1412 procedures included in the analysis.
Trans-radial coronary angiography was performed with the Tiger as the primary catheter in
852 cases (%). Patient characteristics are shown in Table 1. Patients done with the Tiger
catheter were slightly younger and were hypertensive more often than those examined with Judkins
catheters. Overall, crossover from right to left radial access occurred in 5 cases (0.9%) and to
femoral access 59 cases (2.0%). Left transradial procedures were excluded from analysis.
Ostial stability (Fig 1 and Fig 2)
Ostial stability of the Tiger was deemed good in 498 cases (59.5%) and poor in 299 cases
(35.7%). In 40 cases (4.8%), the Tiger failed completely to engage in either ostium. Poor ostial
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Fig 1. Ostial stability of the Tiger. The bar graph shows the distribution of stable (left), completely unstable (mid) and partially unstable
(right) ostial catheter landing when using the Tiger and the Judkins catheters. ªStableº means stable ostial landing in both coronary ostia;
ªunstableº means instable ostial landing in both ostia. ªPartially unstableº means unstable ostial landing in the RCO or LCO.
stability of the Tiger was seen more often in the LCO (290 cases; 34.0%) compared to the RCO
(90 cases, 10.8%, p<0.001) (Fig 1).
A switch to Judkins catheters due to poor or failed ostial engagement of Tiger occurred in
423 cases (33.2%). Compared to 137 TRC-procedures with Judkins catheters, no difference in
the rate of poor ostial stability was found: 40.5% vs. 46.6% (p = 0.183).
Different from the Tiger, poor ostial stability of Judkins catheters was found at an equal rate
in either coronary ostium (LCO 27.4% vs. RCO 26.3%). Poor ostial instability in the RCO
occurred less often with the Tiger catheters compared to Judkins catheters (10.8% vs. 26.3%,
p<0.001). In the left coronary ostium, Judkins catheters were found to have a lesser frequency
of poor ostial engagement (34.4% vs. 27.4%, p = 0.108) (Fig 2).
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Fig 2. Distribution of ostial stability of the Tiger and Judkins catheters. The bar graph demonstrates the distribution of ostial instability
within the RCO and LCO when using the Tiger and the Judkins catheters. Tiger vs. Judkins in the LCO p = 0.108, Tiger vs. Judkins in the RCO
p<0.001, Judkins LCO vs. Judkins in the RCO p = 0.840, Tiger LCO vs. Tiger in the RCO p<0.001.
Contrast volume and fluoroscopy time
Procedures performed with a Tiger catheter were associated with significant less contrast
volume compared to Judkins catheters (65.23 ± 30.69mL vs. 96.63 ± 55.27mL, p<0.001). This
was the case whether or not difficulties with ostial engagement were encountered. Tiger use
resulted in lower contrast volume than Judkins use in cases with good ostial stability (63.48 ±
29.83mL vs. 82 ± 56.58mL, p<0.004), as well as poor ostial stability (69.82 ± 31.76mL vs. 99.67
±48.42mL, p<0.001). Likewise, FT was significantly lower for Tiger compared to Judkins
catheters (198.27 ± 194.85 sec vs. 326.85 ± 329.7 sec, p<0.001), whether or not good ostial stability
was present (Fig 3).
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Fig 3. Dye volume and fluoroscopy time. The left bar graph demonstrates the volume of contrast medium applied by the Tiger and
Judkins catheters in case of stable and unstable ostial landing (not normally distributed data); Tiger: p = 0.004, Judkins: p = 0.075. The
right bar graph shows FT applied under the use of the Tiger and the Judkins in case of stable and instable ostial landing (not normally
distributed data): Tiger p = 0.024, Judkins p = 0.255.
Complications encountered consisted only of forearm hematomas associated with 5F and 6F
sheaths; neither reported were documented spasms of the radial or brachial artery nor
coronary complications. Complication rate of procedures performed with the Tiger catheter was
lower than with Judkins catheters (1.6% vs. 6.6%, p<0.002). It increased slightly to 2.4% when
a switch from Tiger to Judkins catheters was necessary.
The main reason for the development of a one-catheter-concept [
] is the
achievement of shorter fluoroscopy times, less contrast use and less radiation exposure. However, this
goal can only be reached, if the Tiger catheter can deliver a stable engagement in both coronary
ostia. The Tiger catheter has encountered fast growing acceptance, particularly in Asia, where
it was reported to be the preferred catheter in two thirds of TRC's. . The performance of
the Tiger has been investigated only by a small randomised single-centre study of 80 patients
reported by Kim et al. who found successful coronary ostial engagement in 100% of the right
and 91% of the left coronary artery [
]. However, among radialists, its efficacy has been in
doubt, in particular its capability for stable seating in both coronary ostia. Consequently, we
examined its efficacy in a large, retrospective multi-center cohort during routine trans-radial
Our study confirms that the Tiger catheter is a suitable tool for the implementation of the
one-catheter-concept since it obviated the need for a second catheter in two thirds of the cases.
However, poor ostial stability of the Tiger during contrast injection was seen in 35.7% of cases,
of whom two thirds occurred in the left coronary ostium with the Tiger. The same frequency
of ostial instability (33.2%) was encountered with the Judkins catheters which we attribute to
the shapes of the Judkins curves which were designed for femoral access. Ostial instability in
the left coronary artery was significantly more common in the Tiger than in the Judkins left
curve, whereas it was significantly less common in the right coronary artery. Thus, poor
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performance of the Tiger curve predominantly affects the left coronary artery. For the right
coronary artery, performance of the Tiger curve was significantly better than that of the
Judkins right curve.
Not surprisingly, a negative impact of difficult ostial engagement on contrast volume and
FT was confirmed by our results. However, this effect was less pronounced with the Tiger
catheters, which showed this problem equally affects both curves. When we analyzed all cases
regardless of the occurrence of ostial instability, contrast volume and FT were significantly less
when a one-catheter approach was chosen. We believe the reason for this is the superior
performance of the Tiger curve in engaging the right coronary ostium where most of the contrast
volume and FT are spent.
Two previous studies investigating the one-catheter strategy reported contrast volumes
during TRC with ªBrachial Type Kº and the Amplatzer Left (ªALº) procedure of 103 ± 33mL and
114 ± 78mL, respectively [
], which is considerably higher than the amount of the Tiger in
our study (65 ± 31mL). There is no such data about the ªJackyº. However, a direct comparison
to these earlier studies is not possible since coronary angiography in these catheterization
laboratories may have been done in a different manor.
The non-inferiority of ostial stability of the Tiger, less contrast use and shorter FT, as well as
lower complication rates are proof of its efficacy in day-to-day practice. Its mayor disadvantage
is frequent ostial instability in the LCO leading to inadequate filling and switching to Judkins
curves, which was seen in no less than 33% overall. Based on this observation, we advise
operators to avoid using the Tiger catheter for diagnostic angiography in scenarios where a difficult
engagement in the left coronary can be anticipated, such as aortic ectasia of aortic valve stenosis.
Despite this draw-back, contrast use and FT were lower than with the two-catheter approach
with Judkins curves which we believe is due to the vastly superior performance of the Tiger
reaching the RCO. This has implications for patients with renal failure or poor left ventricular
function, in whom contrast use and FT are crucial. In these groups, we propose choosing the
one-catheter-approach with the Tiger or a hybrid approach with Tiger for the right and a
Judkins left catheter for the left coronary artery if Tiger fails to engage promptly. Further
prospective studies are needed to prove this approach to be superior in high risk patients. Finally, we
observed a lower incidence of bleeding complications in the group where the operator intended
to use only the Tiger catheter. Again, we believe that the Tiger one-catheter approach should be
the first choice in patients at high risk of bleeding complications, such as elderly females.
Due to its retrospective study design, catheter performance was measured by judging ostial
stability during contrast injection. This surrogate parameter may only partially reflect ease of
engagement in the coronary ostia. Furthermore, we did not record separately FT for
cannulation of each coronary ostium, nor do we have data on the frequency of switching to another
catheter size or an Amplatz curve. The retrospective nature of our study did not exclude bias
of the operator in his choice of the catheter. Patients in the Judkins group were older than in
the Tiger group possibly reflecting a bias to use conventional catheters for patients deemed
have a more complicated catheterization procedure.
S1 Data. Excel-database.
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The authors like to thank very much Mr. Hedderich (graduated diplomate computer scientist
at the Institute for Medical Informatics and Statistics of the Christian-Albrechts-University,
Kiel) for supervising our biometrical analysis.
Conceptualization: Christoph Langer, Marcus Wiemer.
Data curation: Julia Riehle, Helge Wuttig.
Formal analysis: Christoph Langer.
Funding acquisition: Marcus Wiemer.
Investigation: Christoph Langer, Julia Riehle.
Methodology: Christoph Langer, Marcus Wiemer.
Resources: Helge Wuttig, Stephanie DuÈrrwald, Alexander Samol.
Software: Helge Wuttig.
Supervision: Christoph Langer, Marcus Wiemer.
Validation: Christoph Langer, Julia Riehle.
Visualization: Christoph Langer.
Writing ± original draft: Christoph Langer.
Writing ± review & editing: Helmut Lange, Alexander Samol, Norbert Frey, Marcus Wiemer.
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