Catheter, Simmons

#catheter

The Simmons catheter is a group of reverse-curve selective catheters widely used in the radial access approach for selecting target arteries. In most cases, the catheter must be shaped into its intended configuration (Case 1, Case 2, Case 3, Case 4, Case 6) before it can be used to select the target artery. The catheter features three curves.[1]

Catheter Specifics

Cases

1


Via radial artery access, the traditional way to shape the Simmons 2 catheter involves using the aortic arch.

(A): The Glidewire (black arrow) is advanced into the descending aorta, along with the tip of the Simmons catheter (orange arrow).
(B): The Glidewire is withdrawn proximal to the secondary curve (red arrow).
(C and D): The catheter is slightly twisted and pushed so that the secondary curve herniates down into the ascending aorta.
(E): The catheter is successfully shaped with its tip at the aortic arch-descending aorta junction, the secondary curve in the ascending aorta, and tertiary curve (cyan arrow) in the brachiocephalic artery.

2


In situations where the Glidewire fails to enter the aortic arch, the following technique could be attempted.

(A): Advance the Glidewire (black arrow) into the ascending aorta.
(B): Advance the catheter tip (orange arrow) into the ascending aorta.
(C): Withdraw the Glidewire into the catheter proximal to the primary curve (blue arrow) and point the catheter tip leftward.
(D): Slowly withdraw the catheter until its tip "pops" into the aortic arch.
(E): Gently advance the Glidewire into the descending aorta.
(F): Advance the catheter tip into the descending aorta.

3


Every once in a while, luck strikes, and the Glidewire goes directly into the left CCA, simplifying the forming process.

(A): In this particular case, the Glidewire (black arrow indicates its tip) entered the left CCA directly.
(B): The Simmons catheter followed the Glidewire's path with a gentle advancement while the latter was firmly held (tip out of the view on this PA imagine).
(C) The formation was completed with a slow withdrawal of the Glidewire.

4


In cases where the right brachiocephalic artery presents with a long horizontal segment, the formation of the Simmons catheter via the techniques mentioned above could be challenging. On the other hand, the right CCA (pink arrow) could be utilized for this purpose.

(A): The roadmap of the right brachiocephalic artery indicates a long horizontal segment, consistent with the pre-operative CTA 3D reconstruction image.
(B): The Glidewire (black arrow) is then gently advanced after slightly retracting the tip of the catheter (orange arrow). In this anatomy, the Glidewire tends to bounce back after hitting the end of the horizontal segment and enter the right CCA. If the Glidewire enters the right VA (cyan arrow), it should to be retracted and re-advanced into the right CCA to avoid injury to the smaller right VA.
(C): Gently advance the catheter while holding the Glidewire firmly to navigate to the right CCA until the secondary curve (red arrow) reaches the bend of the wire, thereby forming the catheter into its intended configuration.
(D): Withdraw the Glidewire and perform angiograms of the right CCA/ICA/ECA.

After completing the right CCA/ICA/ECA angiograms, pushing the formed catheter may cause it to advance further into the CCA rather than into the ascending aorta. In such cases, the following technique can be attempted.

(E): Retract the catheter until the secondary curve reaches the right CCA origin.
(F): Advance the stiff end of the Glidewire until it reaches the secondary curve of the catheter.

NB

This must be performed under real-time fluoroscopy to ensure the wire does not protrude from the catheter and potentially injure the right CCA.

(G): Gently advance the catheter and the Glidewire as one piece into the horizontal segment.
(H): Continue advancing until the secondary curve reaches the ascending aorta, and the catheter tip "pops" into the left CCA.
(I): Gently retract the catheter to better engage the left CCA. Remove the Glidewire.

5


This patient presents for a diagnostic cerebral angiography for a left temporal AVM. In this particular case, the distance of the left VA origin to the aortic arch is within the length limit of the Simmons 2 catheter distal to the secondary curve (red arrow), simplifying the selection process.

(A): The catheter tip (orange arrow) appears to be positioned within the left subclavian artery on contrast puff.
(B): The roadmap confirms its position, which is proximal to the origin of the left VA (white arrow).
(C): A gentle pull on the catheter will advance the catheter tip to engage the left VA.
(D): A contrast puff confirms the successful selection of the left VA.

6


After completing the left VA DSA, the Simmons 2 catheter was advanced into the descending aorta. This was a position that prevented the selection of the last target - left CCA (A). The catheter was then retracted into the brachiocephalic artery (B) and advanced into the ascending aorta (C). Selection of the left CCA was achieved (D).

7 Femoral Access


The Simmons 2 catheter could also be utilized for transfemoral access to select target arteries. It can be reformed using the left subclavian artery.

(A): Advance the Glidewire tip (black arrow) into the left subclavian artery.
(B): Advance the catheter tip (orange arrow) into the left subclavian artery while firmly holding the Glidewire.
(C): Withdraw the Glidewire while maintaining the catheter's position.
(D): Withdraw the catheter until the secondary curve (red arrow) reaches the aortic arch.
(E): Twist and advance the catheter to push the secondary curve into the aortic arch.
(F): Push the catheter into the ascending aorta.

Here is another example of using the Simmons 2 catheter via the femoral access in a bovine arch case.


(A-D): Formation of the Simmons 2 catheter into the desired shape.
(E): Selection of the right brachiocephalic artery.
(F): Selection of the left CCA.

  1. Simmons catheter | Radiology Reference Article | Radiopaedia.org ↩︎