Cath Lab Playbook

Out of the packet, every line is full of air. Before the manifold touches a catheter it must hold only saline and contrast, with no bubbles.

1. Hang the saline bag, the contrast bottle and the waste bag. Squeeze and release the contrast controller until it holds contrast.
2. Saline line: port 2 up, port 3 right. Pull: air comes first, then saline. Push it all into the waste bag. Repeat until the syringe fills with bubble-free saline.
3. Contrast line: port 3 up, pull until contrast comes without air. Then port 3 right, port 2 up, and push it to waste.
4. Flush transducer: draw bubble-free saline (port 2 up, pull, then port 2 right). Transducer stopcock up (open to air), port 1 up. Push gently until saline drips from the top with no bubbles. Transducer stopcock back to right.
5. Flush through the front end of the manifold: right, right, right. Hold the syringe tip down and push saline until it drips out with no bubbles.
6. Home: down, right, right. The manifold is primed and waits for the catheter.

Connecting the catheter and zeroing the transducer come once the catheter is in the aorta: section 5.

Watch the oxygen saturation, breathing and blood pressure on the monitor. The reversal drugs are naloxone (for fentanyl) and flumazenil (for midazolam).

The sheath's sidearm ends in a white stopcock. On this kind, the long lever (often marked OFF) points at the port that is closed; the other two ports are connected. Its three ports: the tubing to the sheath (the patient), the syringe port opposite it, and an uncapped side port at 90 degrees to both. At rest the OFF lever points at the patient. Radial and femoral sheaths are flushed the same way.

1. With OFF at the patient, attach a fresh 10 mL syringe of heparinized saline to the syringe port.
2. Turn 180 degrees: OFF at the syringe. The sheath now connects to the side port. Let blood run back out of the side port for a moment. That clears air and stagnant blood without it going near the syringe.
3. Turn 90 degrees: OFF at the side port. The syringe now connects to the sheath. Draw back a little, until you see some blood in the syringe: the line is continuous and free of air.
4. Flush forward into the sheath.
5. Turn 90 degrees back: OFF at the patient. Keep pushing: saline now goes out of the side port and clears the blood from it. Leave the last mL in the syringe.

First catheter: RadialJL3.5 (or the Tiger, if your attending starts with a universal catheter), 5 or 6 French, 100 cm.FemoralJL4, 5 or 6 French, 100 cm.

Flush the catheter until saline drips from its tip. Wipe the 0.035 inch, 150 cm J-wire wet. Straighten the J with one hand: grip the shaft with your middle, ring and little fingers, and pinch the wire with your thumb and index just behind the J. Pull the two grips apart; the stretch straightens the J tip beyond your thumb and index. Keep it stretched and feed the straight tip into the catheter hub. Push the wire through. Stop with the wire tip just inside the catheter tip.

Hold the catheter 3 to 5 cm from the sheath entrance, and push catheter and wire in together, in short strokes, until both are a few centimeters inside the sheath. The wire tip stays just inside the catheter tip while they enter the sheath; the wire only goes ahead in the next step.Radial The arm is on a board: keep the rest of the catheter flat on the drape, not hanging off the edge, so it does not pull back out.

The catheter hub has no stopcock. Put an empty syringe straight onto the hub, pull back until blood comes with no bubbles, take it off, and discard the blood. Let the hub drip while you bring over the manifold's red rotating adapter, and connect wet to wet. First catheter only: connect and zero next (section 5).

With the catheter connected, the manifold still has to be zeroed before the pressure means anything. On your manifold the transducer sits on port 1 with its own small stopcock on top.

1. Check the transducer cable has been handed off the table and plugged into the monitor.
2. Position the transducer at mid-chest height (the phlebostatic axis).
3. Port 1 right: the transducer is cut off from the catheter.
4. Transducer stopcock up: the transducer is open to air.
5. Press ZERO on the monitor. The reading goes to 0.
6. Transducer stopcock back to right (closed to air).
7. Home: down, right, right. The aortic pressure appears.

Re-zero if the table height changes.

RadialJL3.5 from the right radial. The attending advances it toward the left sinus in a shallow LAO view. It often needs a gentle push with a small turn, and a deep breath, to drop into the left main. Coming down from the right subclavian, a catheter behaves about half a size larger than from the femoral; that is why radial starts with JL3.5 where femoral starts with JL4.

RadialTiger (universal), if that is your attending's choice. Advanced into the left sinus, it engages the left main with little or no rotation. It stays in for the right coronary too (section 7).

FemoralJL4 from the femoral. The attending advances it slowly in a shallow LAO view. With the wire out, the JL4 usually drops into the left main by itself as it is advanced. If its tip floats above the ostium and will not reach, the next size up (JL5); if it folds or points down, the next size down (JL3.5).

Compare the tracing with the aortic pressure you recorded. If it damps or ventricularizes, say so out loud and do not inject: the tip is against the wall or there is ostial disease, and the attending will reposition. If it is normal, a small test injection confirms position, then the views.

1. Load: from home, turn port 3 up and pull back slowly. Port 1 stays down, so you keep watching pressure.
2. Tip the syringe down and tap so bubbles rise to the plunger. If there is a lot of air: port 3 right, port 2 up, syringe tip up, push the air to the waste bag, port 2 right, reload.
3. Inject: right, right, right. The pressure trace goes flat while you inject; that is expected.
4. Inject with the tip down: a smooth push, commonly 6 to 10 mL for the left coronary. Never empty the syringe; leave the last few mL.
5. Home: down, right, right. Check the tracing before the next injection.

When blood has sat still in the catheter, or the trace looks damped from a clot or bubble, aspirate through the manifold before the next injection: right, right, right, pull until blood comes with no bubbles, then port 2 up and push it into the waste bag, then home.

Usually five or six views. Common order and what each shows:

Image did not load. View on Wikimedia Commons

Image did not load. View on Wikimedia Commons

The attending disengages the catheter. Disconnect it from the manifold. Reinserting the J-wire: re-wet the J-wire, straighten the tip (pinch and pull), feed it into the catheter end, and advance under fluoro until the J tip emerges from the catheter tip in the ascending aorta.

RadialIf your attending uses a 260 cm exchange-length wire for radial exchanges, this is where it goes in. It is long enough to hold at its back end while the whole catheter comes off, and it stays in the ascending aorta, so the next catheter does not have to find its way around the subclavian again.

Hold the wire still at the catheter end and pull the catheter back.

As you pull the catheter back, once the wire is exposed between the catheter tip and the sheath, grab the wire there.

Wipe the wire as the old catheter comes off. Thread the wire's back end into the JR4's tip How: load onto the wire, and slide the catheter on. Keep going until the wire emerges from the catheter end, then hold the wire there like a rail; advance the JR4 into the sheath, and then let the wire begin leading as you advance back up to the aorta. Then wire out How: wipe and wind, aspirate the hub, connect the manifold, and go home. No need to re-zero.

Bring the catheter to just above the valve in the LAO view, then pull back slightly while rotating it clockwise, about 90 to 180 degrees. The tip turns toward the right sinus and drops into the RCA ostium.

RadialFrom the radial, torque takes longer to reach the tip. The attending turns slowly and lets the tip catch up; turned too fast, it whips past the ostium.

Check the pressure before each injection, exactly as for the left. Injections are smaller: commonly 4 to 6 mL.

Exchange as in section 7 to an angled pigtail, 5 or 6 French, 110 cm. To load it, straighten the loop a little with your fingers so the end hole points at the wire, and load it with the fingertip technique How: load onto the wire. Every LV gram and aortogram is done with a pigtail: the loop keeps the tip off the ventricular wall, and the side holes spread the contrast. Leave the tip in the ascending aorta, just above the aortic valve. Wire out How: wipe and wind, aspirate, connect, home.

RadialThe pigtail comes down the ascending aorta toward the valve the same way. In a tall patient, or with a long arm route, 110 cm may not reach; ask for a longer one.

Contrast in the line damps the pressure. Port 2 up, pull 5 to 10 mL of saline, port 2 right, then right, right, right and push it through, then home.

The attending crosses the aortic valve into the LV with the pigtail. Watch the monitor for ectopy. Record LV pressure. LVEDP is read at end diastole: just after the small a wave, right before the steep upstroke of systole.

1. Disconnect the pigtail from the manifold. Connect the power injector line wet to wet, with no air in the connection.
2. View: usually RAO 30 degrees (some add LAO 45 to 60 for the septum and lateral wall).
3. The tech sets the injector. Common settings are about 30 to 36 mL at 10 to 15 mL/s; your lab's defaults rule.
4. Watch for ectopy during the injection: PVC beats make that part of the gram hard to read.
5. Reconnect the manifold, home. The attending may want a repeat LVEDP.

The pigtail is pulled back from the LV across the valve into the aorta while the pressure is recorded. A drop in systolic pressure as it crosses the valve (a gradient) suggests aortic stenosis. A drop while still inside the LV suggests obstruction below the valve.

1. Pigtail tip in the aortic root, 2 to 3 cm above the valve (above the sinuses), so contrast fills the root without going through the valve.
2. Power injector connected wet to wet. Common settings are about 40 mL at 20 mL/s; your lab's defaults rule.
3. The attending picks the view, often LAO, to open out the root and show any regurgitant jet into the LV.

Ask whether the attending wants the wire back in before the catheter comes out. Many do for curved catheters coming down the arm, so the tip does not catch the vessel wall. If yes: wire in until its tip reaches the catheter tip, then pull catheter and wire out together, under fluoro if there is resistance. The sheath stays until closure.

1. If your band's instructions say so, pull the sheath back 2 to 3 cm.
2. Place the band so its marker sits over the arterial puncture, a few millimetres proximal to the skin entry. Close the strap.
3. Inflate the band (for example Terumo TR Band) with its own syringe, commonly 15 to 18 mL of air, per your unit's protocol, while you slowly pull the sheath out.
4. Let air out slowly until a little blood appears at the site, then put 1 to 2 mL back until it stops. That is patent hemostasis: no bleeding, radial artery still open.
5. Check: pulse oximeter on the thumb, compress the ulnar artery; a waveform means the radial is open.

Manual compression: the ACT usually needs to be below a set value (often 150 to 180 seconds). Find the pulse 1 to 2 cm above the skin entry, pull the sheath in one smooth motion, and press firmly with two or three fingers over the arterial puncture. Hold firm pressure, then ease gradually, usually 15 to 20 minutes in total. Check the site and the distal pulses.

Closure devices such as Angio-Seal (6 or 8 French: an anchor inside the artery and a collagen plug outside) or Perclose ProGlide (a suture across the puncture) need a femoral angiogram showing a suitable puncture site; follow the device's steps and the attending.