I am not familiar with ALR, it may not be available in the US. I looked it up, and it seems like an intermediate catheter between AL1 and AR2. AL is an aggressive catheter with a higher risk of dissection if one is not experienced with it. I suggest one gets experience using the more benign diagnostic AL catheter in diagnostic cases before using the AL guiding catheter.

The RCA is at the top of the sinus of Valsalva, about 1.5 cm above the aortic valve. More importantly, it is important to understand the geometry. Look at Figures 09:07, 12:26 and 15:27. Early in one's career, it may be a good idea to use non-selective puffs, as I explain under 12:26: -if you see the "nest" of the right sinus (cusp), you may be too low -if you see the straight line of the aortic convexity, you are too high -if you see the left coronary artery filling, you are in the left cusp, which also means you are too high compared to the RCA. Torque your catheter to point it to the right and push it back down to the valve/right cusp. -The catheter tends to be pulled high in radial cases (vs tends to dive low and get stuck in the "nest" in femoral cases, where you need to exert more pulling tension while torquing) -The catheter tends to be pulled too high when the aorta is elongated and horizontal, in which case the RCA origin is almost at the same vertical level as the aortic valve (16:40 and 17:06). You recognize that the aorta is nearly horizontal by the way the catheter is lying in the aorta -If your puffs show you are in the right sinus (the "nest"), not too high, yet you cannot see any RCA filling non-selectively in LAO, it is time to consider that the RCA may have anterior takeoff. Try to engage the RCA by making the catheter look at you in LAO, rather than look to the right, or use RAO.

@@eliashanna8248 thank you very much for your excellent explanation. Much appreciated !

Thank you Dr Hanna for patiently repeating concepts. I canulate the RCA a lot easier now!!

It is a good idea. However, I favor any of the following: -If JR is not deep in the conus, keep clocking (to point to the more posterior RCA), while pulling on it to elongate it and make it point down -If JR is deep in the conus, counterclock to disengage, then try to engage while further pulling on the catheter than you did the first time, to elongate it and make it point down -Get a catheter that points more down, like JR5 or AR1

Good point. I have discussed this issue in other talks, esp the more recent one this year. kzfaq.info/get/bejne/ebV2ldhhl7CWiKc.html AND kzfaq.info/get/bejne/eqmJiLBqsc6-cWQ.html It happens especially in upright/vertical ascending aorta and small cusps, where the catheter keeps jumping to the higher LCA level. At this point, the catheter is already too high. When this happens, I would counterclock to make the catheter look toward the right, then push it down to the right cusp, see that it is falling to a lower level, then pull it with a clock. Keep the catheter low at all times: I often don't just pull, but pull and push to transmit the torque yet keep the catheter low at all times.