The use of the guiding catheter in coronary angioplasty: the technique of manipulating catheters to obtain the necessary power to cross tight coronary stenoses.

We have examined a small selection of helpful maneuvers to facilitate passage of a balloon through tight stenoses. Selection of the appropriate guiding catheter is a critical early decision. Changing guiding catheters may be the most expeditious way to solve a "difficult case." The various options for deep engagement of the guiding catheter into the coronary orifice to gain power for crossing resistant lesions have been examined and the potential risks enumerated. The operator must be willing carefully to chart a course to avoid vessel occlusion, pressure damping, dye trapping, intimal damage, and dissection. Sudden disengagement of the guiding catheter from the coronary and vessel spasm must be prevented. Selective use of the "balloon traction maneuver," if judiciously applied, may lead to higher success rates. Guiding catheters and balloons will continue to evolve and hopefully become easier to use. The continued development of smaller deflated balloon profiles with slippery surfaces and better power transmission characteristics will undoubtedly make the vigorous techniques mentioned above less necessary to master in the future.