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CHOICE AND USE OF APPROPRIATE
GUIDEWIRE IN PCI

SAJY KURUTTUKULAM
CONTENTS
 COMPONENTS OF A GUIDE WIRE
 WORKHORSE WIRE
 WIRES FOR DIFFERENT OCCASIONS
 TRACKABILITY

 KNOW YOUR WIRE
 ...
COMPONENTS OF A WIRE
core,
 distal tip and
 outer covering.
CORE
 The inner part of the guide wire is referred to as
the core.
 Extends throughout the shaft of the wire

 It is th...
CORE MATERIALS
 Stainless steel (Majority) /
 Nitinol (BMW)
 Tru-torque SS(Asahi), Durasteel (Galeo).

Dual Core – Niti...
CORE MATERIALS
Stainless steel
Provides excellent support, pushability, torque,
good shapability.
BUT
Less flexible in com...
CORE-MATERIALS
 NITINOL
Excellent flexibility, steering
Kink resistant
 Negative

Less torqueability than SS
Workhorse Guidewires
 ATW/ATW Marker

• Stabilizer
• BMW / BMW Universal
• Zinger
• Cougar XT
• Asahi Light / Medium
• As...
How to test
guidewire
support



 Test method: measure the force
required for 60° bending at
different distances from th...
CTO Wire properties
(1)Tip load
Floppy wires
<1g
CTO Wires
>3g
The selection of a guidewire
 essential component
 INFLUENCED BY
 vessel anatomy

 the lesion morphology
 the devices...
LEFT MAIN PCI
 The choice of a guidewire is not of critical importance.
 Wire selection usually includes spring tip guid...
LEFT MAIN PCI
 The choice of a guidewire is not of critical importance.
 Wire selection usually includes spring tip guid...
BIFURCATION PCI
 In the presence of difficulties accessing the side

branch some hydrophilic wires such as the ChoICE™
PT...
DISSECTIONS
 ChOICE Floppy
 Asahi Soft .
 The parallel wire technique can be recommended if a

dissection plane is ente...
CALCIFIED LESIONS
 ChoICE Floppy (Boston Scientific).
 If it fails to cross the lesion, the next step is to choose

flop...
Iron-man

Grand-Slam

ES – Extra-Support
Floppy
TORTUOUS ANATOMY
 very floppy wire with support for device

delivery could be used
 BMW
 FIELDER FC
 WHISPER ES
 WIGG...
MAIN
VESSEL
TRACKING
Short
tapering
better
Tip load and support for Asahi Intecc
guidewires
CTO Wires

Non-coated /
Hydrophobic
TIP
Non-tapered Tapered
Miracle 3,4.5,6

Cross It 100 - 400

Hydrophilic
TIP
Non-taper...
CTO GUIDE WIRE TECNIQUES
PENETRATION FORCE
 . The “penetration force” of a wire depends on both the

tip load and the cross-sectional area of the ...
THANK YOU
Lesion specific CTO approaches

SLIDING

 Micro-channels present
 ISR total occlusions
 STAR technique

Hydrophilic wir...
Lesion specific CTO approaches

SLIDING

• Pilot, Whisper
• Fielder wires

• Cordis – Shinobi

Hydrophilic wires
Lesion specific CTO approaches

DRILLING
(controlled)

“Workhorse technique”
Most CTOs with discrete
entry point after ini...
Lesion specific CTO approaches

DRILLING
(controlled)

“Workhorse technique”
• Miracle 3, 4.5, 6
• Cross It 100, 200, 300
...
Lesion specific CTO approaches

Penetration

• Blunt entry point
• Heavily calcific or resistant lesions
•

Alternative to...
Lesion specific CTO approaches

Penetration

Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm

Super stiff
tap...
WHICH WIRE WILL NOT PERFORATE
ANY WIRE WILL PERFORATE
Dock extension
Tip load and support for Asahi Intecc
guidewires
Wire types - Support
 – Light




ChoICE™ Floppy - Boston Scientific;
Asahi Light - Abbot Vascular;
Whisper LS - Abbot...
HOW TO CLASSIFY
CORONARY GUIDE WIRES?
CLASSIFICATION
 NO UNIFORM CLASSIFICATION
 BUT SOME CATEGORISATION
purpose of the coating
 To reduce frictions by facilitating the movement of the

wire within the coronary anatomy and acr...
types of coatings
 Hydrophilic coatings attract water and are applied over

the entire working length of the wire, includ...
 Hydrophobic coatings are silicone based coatings

which repel water and are applied on the working
length of the wire, w...
SPECIFIC PURPOSE WIRES
 PRESSURE WIRE
 MARKER WIRE
 ROTABLATOR WIRE
 WIGGLE WIRE
“Support”
 Indicator of the core strength
 More stronger the core – more support
Iron-man

Grand-Slam

ES – Extra-Support
Floppy
Wire types - Support
 – Light




ChoICE™ Floppy - Boston Scientific;
Asahi Light - Abbot Vascular;
Whisper LS - Abbot...
Pseudostenosis caused by wire in
tortuous vessel
GUIDEWIRES
FOR CTO
Core - to - tip

Shaping ribbon
(2) Hydrophilic coating - Slippery
(3) Tapering of wire tip.
CTO Wires (Stiffer)

Non-coated /
Hydrophobic
TIP
Non-tapered Tapered
Miracle 3,4.5,6

Cross It 100 - 400

Hydrophilic
TIP...
Tapered

wires

Pros:
 Minimizes tip resistance and
 Select small vascular micro-channels within the CTO.
Cons
 These n...
CTO guide wire techniques
Tip load and support for Asahi Intecc
guidewires
Lesion specific CTO approaches

SLIDING

 Micro-channels present
 ISR total occlusions
 STAR technique

Hydrophilic wir...
Lesion specific CTO approaches

SLIDING

• Pilot, Whisper
• Fielder wires

• Cordis – Shinobi

Hydrophilic wires
Lesion specific CTO approaches

DRILLING
(controlled)

“Workhorse technique”
Most CTOs with discrete
entry point after ini...
Lesion specific CTO approaches

DRILLING
(controlled)

“Workhorse technique”
• Miracle 3, 4.5, 6
• Cross It 100, 200, 300
...
Lesion specific CTO approaches

Penetration

• Blunt entry point
• Heavily calcific or resistant lesions
•

Alternative to...
Lesion specific CTO approaches

Penetration

Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm

Super stiff
tap...
purpose of the coating
 To reduce frictions by facilitating the movement of the

wire within the coronary anatomy and acr...
types of coatings
 Hydrophilic coatings attract water and are applied over

the entire working length of the wire, includ...
 Hydrophobic coatings are silicone based coatings

which repel water and are applied on the working
length of the wire, w...
 ASAHI Soft
 Tip load: 1.0 g

Radiopaque length: 3 cm
Outside diameter: 0.014"
Coating: Hydrophobic
Tip style: Core to t...
PROPERTIES OF AN IDEAL
GUIDEWIRE
 Several properties are desirable in an ideal

guidewire, but no single guidewire may po...
Biomed Tech 2012; 57 (Suppl. 1) ©
2012
 CLASSIFICATION
 PROPERTIES OF AN IDEAL WIRE
 COMPONENTS OF A GUIDE WIRE
 WORKHORSE WIRE

 WIRES FOR SPECIAL OCCASION...
stent
delivery systems
stent
delivery systems
 friction properties and flexibility of the stent system
 constitution of the vessel
 properties...
Biomed Tech 2012; 57 (Suppl. 1) ©
2012
 HI-TORQUE BALANCE
 Tip load: 0.6 g

Radiopaque length: 3 or 40
cm
Outside diameter: 0.014"
Tip Outside diameter:
0.014"...
 Components of a

guidewire. There are
three main components
of guidewire structure:
core, distal tip and outer
covering....
Any wire can perforate
WIRE COATING
Coating
 The coating is the outer covering on the core that

keeps the overall diameter consistent and
influences the wir...
Wire types – based on coating
 – Hydrophilic coating
 (ChoICE Floppy - Boston Scientific;
 PT Graphix- Boston Scientifi...
Hydrophilic wires
Eg. Hydrotrack (Medtronic), M coat
(Terumo)
Hydrocoat (Pilot)

PROS
 Offer good manoeuvrability in tort...
Non-Coated / Hydrophobic wires
Pros
 More controllable (and therefore less likely to dissect)
 Provide better tactile fe...
purpose of the coating
 To reduce frictions by facilitating the movement of the

wire within the coronary anatomy and acr...
types of coatings
 Hydrophilic coatings attract water and are applied over

the entire working length of the wire, includ...
 Hydrophobic coatings are silicone based coatings

which repel water and are applied on the working
length of the wire, w...
 ASAHI Soft
 Tip load: 1.0 g

Radiopaque length: 3 cm
Outside diameter: 0.014"
Coating: Hydrophobic
Tip style: Core to t...
Workhorse Guidewires
 ATW/ATW Marker

• Stabilizer
• BMW / BMW Universal
• Zinger
• Cougar XT
• Asahi Light / Medium
• As...
PROPERTIES OF AN IDEAL
GUIDEWIRE
 Several properties are desirable in an ideal

guidewire, but no single guidewire may po...
Guidewires for PCI

Harikrishnan.S
SCTIMST
www.sctimst.ac.in
1977

Blunt, closed-end,
Inner balloon catheter with a
short guide-wire attached to its tip
• Non-manoeuvrable catheter.
•...
1982
John B Simpson et al reported the
first experience with a new over-thewire balloon system.
Could be passed beyond the...
Anatomy of guide wires
Wire tip

 Wire tip – important component.
 Decides the wire characteristics

 CTO Wires
Radio-opaque tip

 Visibility of the wire tip is provided by
radiopaque platinum coils that are usually
placed at the dis...
Standard wire structure
 0.014 inch diameter
 Tapered tip to 0.009/0.010 in some
 PTFE coating – whole length.
 Tip – ...
Runthrough NS

Dual Core
Tortuous wires

Wiggle wire
BOSTON
Forté® Floppy Marker Wire

Tip Radiopacity: 2cm; two 5mm marker system
enhanced precision and control
turn-for-turn torque response.
How to select guide wires for
CTO?
 Start with a Soft wire

Floppy wires
Hydrophilic floppy wire
 Then go to harder (sti...
Side branch at CTO

1. Hydrophilic wires
may not succeed.

2.Careful penetration
to enter the plaque.
KINETIX Guidewire.
Replaces conventional spring coil design,
to provide more efficient energy transfer
from physician hand...
Guide wires for PCI

 Guidewire selection depends on the
patient, vessel and lesion characteristics.

 Guide wire select...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
 ...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
 ...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
 ...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
 ...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),

 TIP COATING(hydrophilic hydrophobic, No coating)
 ...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),
 TIP COATING(hydrophilic hydrophobic, No coating)
 T...
CATEGORISATION
 TIP FLEXIBILITY(floppy/soft, intermediate, stiff),
 TIP COATING(hydrophilic hydrophobic, No coating)
 T...
Thank you
Thank you
 Components of a
guidewire. There are

three main
components of
guidewire structure:
core, distal tip and
outer covering....
Components of a guide wire
 Core
 Outer covering

 Distal tip
The effect of different guide
wires on the trackability of
coronary stent
delivery systems
The effect of different guide
wires on the trackability of
coronary stent
 friction properties and flexibility of the ste...
 HI-TORQUE BALANCE
 Tip load: 0.6 g

Radiopaque length: 3 or 40
cm
Outside diameter: 0.014"
Tip Outside diameter:
0.014"...
TIP DESIGN
 CORE TO TIP

 SHAPING BALLOON
GUIDEWIRES
FOR CTO
Core - to - tip

Shaping ribbon
CTO Wire properties

(1)Tip load
Floppy wires
<1g
CTO Wires
>3g
(2) Hydrophilic coating - Slippery
(3) Tapering of wire tip.
CTO Wires (Stiffer)
Non-coated /
Hydrophobic
TIP
Non-tapered Tapered
Miracle 3,4.5,6

Cross It 100 - 400

Hydrophilic
TIP
...
Tapered wires
Pros:
 Minimizes tip resistance and
 Select small vascular micro-channels within the CTO.

Cons
 These ne...
CTO guide wire techniques
Lesion specific CTO approaches
SLIDING

 Micro-channels present
 ISR total occlusions
 STAR technique

Hydrophilic wire...
Lesion specific CTO approaches
SLIDING

• Pilot, Whisper
• Fielder wires

• Cordis – Shinobi

Hydrophilic wires
Lesion specific CTO approaches
DRILLING
(controlled)

“Workhorse technique”
Most CTOs with discrete
entry point after init...
Lesion specific CTO approaches
DRILLING
(controlled)

“Workhorse technique”
• Miracle 3, 4.5, 6
• Cross It 100, 200, 300
•...
Lesion specific CTO approaches

Penetration

• Blunt entry point
• Heavily calcific or resistant lesions
•

Alternative to...
Lesion specific CTO approaches

Penetration

Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm

Super stiff
tap...
(2) Hydrophilic coating - Slippery
(3) Tapering of wire tip.
Core - to - tip

Shaping ribbon
Any wire can perforate
Core characteristics
 Core diameter
Larger diameters improve the support.
Lesser diameter more flexibility.
Larger diamet...
“Support”
 Indicator of the core strength
 More stronger the core – more support
REFERNCES
 JACC INTERVENTIONS APRIL2012
 PCR-EAPCI TEXT BOOK
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
Choice And Use Of Appropriate Guidewire In PCI
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COMPONENTS OF A GUIDE WIRE
WORKHORSE WIRE
WIRES FOR DIFFERENT OCCASIONS
TRACKABILITY
KNOW YOUR WIRE
CLASSIFICATION
PROPERTIES OF AN IDEAL WIRE

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Transcript of "Choice And Use Of Appropriate Guidewire In PCI"

  1. 1. CHOICE AND USE OF APPROPRIATE GUIDEWIRE IN PCI SAJY KURUTTUKULAM
  2. 2. CONTENTS  COMPONENTS OF A GUIDE WIRE  WORKHORSE WIRE  WIRES FOR DIFFERENT OCCASIONS  TRACKABILITY  KNOW YOUR WIRE  CLASSIFICATION  PROPERTIES OF AN IDEAL WIRE
  3. 3. COMPONENTS OF A WIRE core,  distal tip and  outer covering.
  4. 4. CORE  The inner part of the guide wire is referred to as the core.  Extends throughout the shaft of the wire  It is the stiffest part of the wire that gives the stability and steerability to the guide wire.
  5. 5. CORE MATERIALS  Stainless steel (Majority) /  Nitinol (BMW)  Tru-torque SS(Asahi), Durasteel (Galeo). Dual Core – Nitinol + Stainless steel 
  6. 6. CORE MATERIALS Stainless steel Provides excellent support, pushability, torque, good shapability. BUT Less flexible in comparison to newer core materials and more susceptible to kinking.
  7. 7. CORE-MATERIALS  NITINOL Excellent flexibility, steering Kink resistant  Negative Less torqueability than SS
  8. 8. Workhorse Guidewires  ATW/ATW Marker • Stabilizer • BMW / BMW Universal • Zinger • Cougar XT • Asahi Light / Medium • Asahi Standard • Asahi Prowater Flex • Choice Floppy • Luge • IQ • Forte Floppy • Runthrough NS • Galeo
  9. 9. How to test guidewire support   Test method: measure the force required for 60° bending at different distances from the tip
  10. 10. CTO Wire properties (1)Tip load Floppy wires <1g CTO Wires >3g
  11. 11. The selection of a guidewire  essential component  INFLUENCED BY  vessel anatomy  the lesion morphology  the devices to be used  operator's experience and preference.
  12. 12. LEFT MAIN PCI  The choice of a guidewire is not of critical importance.  Wire selection usually includes spring tip guidewire designed for frontline lesions, for example, ChoICE™ Floppy (Boston Scientific), Hi-Torque Balance Middleweight (Abbott Vascular)
  13. 13. LEFT MAIN PCI  The choice of a guidewire is not of critical importance.  Wire selection usually includes spring tip guidewire designed for frontline lesions, for example, ChoICE™ Floppy (Boston Scientific), Hi-Torque Balance Middleweight (Abbott Vascular)  FOR LEFT MAIN OR RCA OSTIAL PCI AN EXTRASUPPORT WIRE IS PREFERED
  14. 14. BIFURCATION PCI  In the presence of difficulties accessing the side branch some hydrophilic wires such as the ChoICE™ PT Floppy (Boston Scientific), PT Graphix™ (Boston Scientific) or Asahi Fielder (Abbott Vascular) may become useful. These wires have higher risk to perforate the distal vessel if allowed to migrate into small side branched or too distally. Therefore it is important to monitor the distal position of the wire tip. These wires also should not to be jailed because of the risk of wire rupture during pullback.
  15. 15. DISSECTIONS  ChOICE Floppy  Asahi Soft .  The parallel wire technique can be recommended if a dissection plane is entered with the first wire  Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi H, Obara C. The latest wire technique for chronic total occlusion. Ital Heart J 2005;6:489-93..
  16. 16. CALCIFIED LESIONS  ChoICE Floppy (Boston Scientific).  If it fails to cross the lesion, the next step is to choose floppy hydrophilic wire such as the ChoICE PT Floppy (Boston Scientific) or Asahi Fielder (Abbott Vascular)
  17. 17. Iron-man Grand-Slam ES – Extra-Support Floppy
  18. 18. TORTUOUS ANATOMY  very floppy wire with support for device delivery could be used  BMW  FIELDER FC  WHISPER ES  WIGGLE WIRE
  19. 19. MAIN VESSEL TRACKING Short tapering better
  20. 20. Tip load and support for Asahi Intecc guidewires
  21. 21. CTO Wires Non-coated / Hydrophobic TIP Non-tapered Tapered Miracle 3,4.5,6 Cross It 100 - 400 Hydrophilic TIP Non-tapered Pilot 50,100,150 Tapered Conquest Pro
  22. 22. CTO GUIDE WIRE TECNIQUES
  23. 23. PENETRATION FORCE  . The “penetration force” of a wire depends on both the tip load and the cross-sectional area of the wire tip.  For wires of similar tip dimension, those with greater tip load are stiffer and have greater penetration force and pushability than ones with smaller tip load For wires having similar tip load, those with a tapered end have greater penetration force than ones with an untapered end.
  24. 24. THANK YOU
  25. 25. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  26. 26. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  27. 27. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” Most CTOs with discrete entry point after initial attempt with soft (intermediate wires) Stiff , hydrophobic non-tapered wires
  28. 28. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” • Miracle 3, 4.5, 6 • Cross It 100, 200, 300 • Medtronic Persuader 3,6 gm Stiff , hydrophobic non-tapered wires
  29. 29. Lesion specific CTO approaches Penetration • Blunt entry point • Heavily calcific or resistant lesions • Alternative to “drilling” as the “work horse technique” after initial soft wire failure Super stiff tapered wires
  30. 30. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  31. 31. WHICH WIRE WILL NOT PERFORATE
  32. 32. ANY WIRE WILL PERFORATE
  33. 33. Dock extension
  34. 34. Tip load and support for Asahi Intecc guidewires
  35. 35. Wire types - Support  – Light    ChoICE™ Floppy - Boston Scientific; Asahi Light - Abbot Vascular; Whisper LS - Abbott Vascular;  – Moderate support    PT Graphix - Boston Scientific; Whisper MS - Abbott Vascular; Balance Middleweight – Abbott Vascular.  – Extra support    ChoICE™ Extra Support - Boston Scientific; Mailman – Boston Scientific; Asahi Grand Slam - Abbott Vascular
  36. 36. HOW TO CLASSIFY CORONARY GUIDE WIRES?
  37. 37. CLASSIFICATION  NO UNIFORM CLASSIFICATION  BUT SOME CATEGORISATION
  38. 38. purpose of the coating  To reduce frictions by facilitating the movement of the wire within the coronary anatomy and across the lesion, helping the wire negotiate tortuous anatomy, — To improve deliverability by facilitating the movement of interventional equipment over the wire.
  39. 39. types of coatings  Hydrophilic coatings attract water and are applied over the entire working length of the wire, including tip coils. When dry, the coating is a thin, non-slippery solid. Upon contact with liquids, such as saline or blood, the coating becomes a slippery gel-like surface that acts to reduce friction with the vessel walls and increase trackability. Hydrophilic coating provides a lubricious, low friction feel inside the vessel and more trackability.
  40. 40.  Hydrophobic coatings are silicone based coatings which repel water and are applied on the working length of the wire, with the exception of the distal tip. They require no activation by liquids to create a "waxlike" surface and to achieve the desired effect — to reduce friction and increase trackability of the wire. Silicone coating has higher friction, more stable feel inside the vessel.
  41. 41. SPECIFIC PURPOSE WIRES  PRESSURE WIRE  MARKER WIRE  ROTABLATOR WIRE  WIGGLE WIRE
  42. 42. “Support”  Indicator of the core strength  More stronger the core – more support
  43. 43. Iron-man Grand-Slam ES – Extra-Support Floppy
  44. 44. Wire types - Support  – Light    ChoICE™ Floppy - Boston Scientific; Asahi Light - Abbot Vascular; Whisper LS - Abbott Vascular;  – Moderate support    PT Graphix - Boston Scientific; Whisper MS - Abbott Vascular; Balance Middleweight – Abbott Vascular.  – Extra support    ChoICE™ Extra Support - Boston Scientific; Mailman – Boston Scientific; Asahi Grand Slam - Abbott Vascular
  45. 45. Pseudostenosis caused by wire in tortuous vessel
  46. 46. GUIDEWIRES FOR CTO
  47. 47. Core - to - tip Shaping ribbon
  48. 48. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  49. 49. CTO Wires (Stiffer) Non-coated / Hydrophobic TIP Non-tapered Tapered Miracle 3,4.5,6 Cross It 100 - 400 Hydrophilic TIP Non-tapered Pilot 50,100,150 Tapered Conquest Pro
  50. 50. Tapered wires Pros:  Minimizes tip resistance and  Select small vascular micro-channels within the CTO. Cons  These needle like tips can also easily dissect and perforate the vessel wall.
  51. 51. CTO guide wire techniques
  52. 52. Tip load and support for Asahi Intecc guidewires
  53. 53. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  54. 54. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  55. 55. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” Most CTOs with discrete entry point after initial attempt with soft (intermediate wires) Stiff , hydrophobic non-tapered wires
  56. 56. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” • Miracle 3, 4.5, 6 • Cross It 100, 200, 300 • Medtronic Persuader 3,6 gm Stiff , hydrophobic non-tapered wires
  57. 57. Lesion specific CTO approaches Penetration • Blunt entry point • Heavily calcific or resistant lesions • Alternative to “drilling” as the “work horse technique” after initial soft wire failure Super stiff tapered wires
  58. 58. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  59. 59. purpose of the coating  To reduce frictions by facilitating the movement of the wire within the coronary anatomy and across the lesion, helping the wire negotiate tortuous anatomy, — To improve deliverability by facilitating the movement of interventional equipment over the wire.
  60. 60. types of coatings  Hydrophilic coatings attract water and are applied over the entire working length of the wire, including tip coils. When dry, the coating is a thin, non-slippery solid. Upon contact with liquids, such as saline or blood, the coating becomes a slippery gel-like surface that acts to reduce friction with the vessel walls and increase trackability. Hydrophilic coating provides a lubricious, low friction feel inside the vessel and more trackability.
  61. 61.  Hydrophobic coatings are silicone based coatings which repel water and are applied on the working length of the wire, with the exception of the distal tip. They require no activation by liquids to create a "waxlike" surface and to achieve the desired effect — to reduce friction and increase trackability of the wire. Silicone coating has higher friction, more stable feel inside the vessel.
  62. 62.  ASAHI Soft  Tip load: 1.0 g Radiopaque length: 3 cm Outside diameter: 0.014" Coating: Hydrophobic Tip style: Core to tip Polymer cover: none
  63. 63. PROPERTIES OF AN IDEAL GUIDEWIRE  Several properties are desirable in an ideal guidewire, but no single guidewire may possess all of them. Guidewires must be chosen based on the requirement of an individual case.
  64. 64. Biomed Tech 2012; 57 (Suppl. 1) © 2012
  65. 65.  CLASSIFICATION  PROPERTIES OF AN IDEAL WIRE  COMPONENTS OF A GUIDE WIRE  WORKHORSE WIRE  WIRES FOR SPECIAL OCCASIONS  TRACKABILITY
  66. 66. stent delivery systems
  67. 67. stent delivery systems  friction properties and flexibility of the stent system  constitution of the vessel  properties of the guide wire
  68. 68. Biomed Tech 2012; 57 (Suppl. 1) © 2012
  69. 69.  HI-TORQUE BALANCE  Tip load: 0.6 g Radiopaque length: 3 or 40 cm Outside diameter: 0.014" Tip Outside diameter: 0.014" Coating: Hydrophilic or phobic Tip style: Shaping Ribbon Polymer cover: none Core Material: ELASTINITE Nitinol
  70. 70.  Components of a guidewire. There are three main components of guidewire structure: core, distal tip and outer covering. The design of the guidewire tip: (A) core-to-tip, (B) shaping ribbon.
  71. 71. Any wire can perforate
  72. 72. WIRE COATING
  73. 73. Coating  The coating is the outer covering on the core that keeps the overall diameter consistent and influences the wire performance.  Almost all wires have a proximal PTFE coating.  “True coating” Distal tip – 30 cm  To reduce friction  To increase maneuverability
  74. 74. Wire types – based on coating  – Hydrophilic coating  (ChoICE Floppy - Boston Scientific;  PT Graphix- Boston Scientific;  Asahi Fielder - Abbott Vascular)  – Hydrophobic coating  Asahi Soft - AbbottVascular  - Non-coated
  75. 75. Hydrophilic wires Eg. Hydrotrack (Medtronic), M coat (Terumo) Hydrocoat (Pilot) PROS  Offer good manoeuvrability in tortuous vessels. CONS  More likely to penetrate beneath plaque and dissect  Hydrophilic wires also tend to select small branches or vasavasorum and perforate more frequently.
  76. 76. Non-Coated / Hydrophobic wires Pros  More controllable (and therefore less likely to dissect)  Provide better tactile feel Cons  Poor trackability  Wire tip becomes stiffer, torque response increases, but less tip resistance is transmitted to the operator, making it easier to enter a false channel.
  77. 77. purpose of the coating  To reduce frictions by facilitating the movement of the wire within the coronary anatomy and across the lesion, helping the wire negotiate tortuous anatomy, — To improve deliverability by facilitating the movement of interventional equipment over the wire.
  78. 78. types of coatings  Hydrophilic coatings attract water and are applied over the entire working length of the wire, including tip coils. When dry, the coating is a thin, non-slippery solid. Upon contact with liquids, such as saline or blood, the coating becomes a slippery gel-like surface that acts to reduce friction with the vessel walls and increase trackability. Hydrophilic coating provides a lubricious, low friction feel inside the vessel and more trackability.
  79. 79.  Hydrophobic coatings are silicone based coatings which repel water and are applied on the working length of the wire, with the exception of the distal tip. They require no activation by liquids to create a "waxlike" surface and to achieve the desired effect — to reduce friction and increase trackability of the wire. Silicone coating has higher friction, more stable feel inside the vessel.
  80. 80.  ASAHI Soft  Tip load: 1.0 g Radiopaque length: 3 cm Outside diameter: 0.014" Coating: Hydrophobic Tip style: Core to tip Polymer cover: none
  81. 81. Workhorse Guidewires  ATW/ATW Marker • Stabilizer • BMW / BMW Universal • Zinger • Cougar XT • Asahi Light / Medium • Asahi Standard • Asahi Prowater Flex • Choice Floppy • Luge • IQ • Forte Floppy • Runthrough NS • Galeo
  82. 82. PROPERTIES OF AN IDEAL GUIDEWIRE  Several properties are desirable in an ideal guidewire, but no single guidewire may possess all of them. Guidewires must be chosen based on the requirement of an individual case.
  83. 83. Guidewires for PCI Harikrishnan.S SCTIMST www.sctimst.ac.in
  84. 84. 1977 Blunt, closed-end, Inner balloon catheter with a short guide-wire attached to its tip • Non-manoeuvrable catheter. • Impossible to perform independent movements of the wire and balloon.
  85. 85. 1982 John B Simpson et al reported the first experience with a new over-thewire balloon system. Could be passed beyond the coronary stenosis, providing a platform for the subsequent delivery of the balloon catheter.
  86. 86. Anatomy of guide wires
  87. 87. Wire tip  Wire tip – important component.  Decides the wire characteristics  CTO Wires
  88. 88. Radio-opaque tip  Visibility of the wire tip is provided by radiopaque platinum coils that are usually placed at the distal tip 2 to 3 cm in length, but maybe much longer.  Galeo Wires – 3 cm distal radio-opaque tip.  BMW wire – 3 cm distal radio-opaque tip
  89. 89. Standard wire structure  0.014 inch diameter  Tapered tip to 0.009/0.010 in some  PTFE coating – whole length.  Tip – coated/non-coated  Tip has a radioopaque platinum coil.
  90. 90. Runthrough NS Dual Core
  91. 91. Tortuous wires Wiggle wire
  92. 92. BOSTON Forté® Floppy Marker Wire Tip Radiopacity: 2cm; two 5mm marker system
  93. 93. enhanced precision and control turn-for-turn torque response.
  94. 94. How to select guide wires for CTO?  Start with a Soft wire Floppy wires Hydrophilic floppy wire  Then go to harder (stiffer) wires Tapered tip wires Tapered and hydrophilic tip  Always exchange the stiff wire for a soft wire once crossed
  95. 95. Side branch at CTO 1. Hydrophilic wires may not succeed. 2.Careful penetration to enter the plaque.
  96. 96. KINETIX Guidewire. Replaces conventional spring coil design, to provide more efficient energy transfer from physician hand to guide wire tip, for turn-for-turn torque response.
  97. 97. Guide wires for PCI  Guidewire selection depends on the patient, vessel and lesion characteristics.  Guide wire selection is crucial for a safe and successful procedure.
  98. 98. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),
  99. 99. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING
  100. 100. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)
  101. 101. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE
  102. 102. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING
  103. 103. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING(tapered, untapered),  CORE MATERIAL
  104. 104. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING(tapered, untapered),  CORE MATERIAL(stainless steel, Nitinol, high-tensile stainless steel),  DEVICE SUPPORT
  105. 105. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING(tapered, untapered),  CORE MATERIAL(stainless steel, Nitinol, high-tensile stainless steel),  DEVICE SUPPORT
  106. 106. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING(tapered, untapered),  CORE MATERIAL(stainless steel, Nitinol, high-tensile stainless steel),  DEVICE SUPPORT(light, moderate support, extra support),  TARGET LESION
  107. 107. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE(one-piece core-to-tip, two-piece core with shaping ribbon),  TIP TAPERING(tapered, untapered),  CORE MATERIAL(stainless steel, Nitinol, high-tensile stainless steel),  DEVICE SUPPORT(light, moderate support, extra support),  TARGET LESION(workhorse/frontline wires, CTO wires, wires for tortuous lesions,
  108. 108. Thank you Thank you
  109. 109.  Components of a guidewire. There are three main components of guidewire structure: core, distal tip and outer covering. The design of the guidewire tip: (A) core-to-tip, (B) shaping ribbon.
  110. 110. Components of a guide wire  Core  Outer covering  Distal tip
  111. 111. The effect of different guide wires on the trackability of coronary stent delivery systems
  112. 112. The effect of different guide wires on the trackability of coronary stent  friction properties and flexibility of the stent delivery systems system  constitution of the vessel  properties of the guide wire
  113. 113.  HI-TORQUE BALANCE  Tip load: 0.6 g Radiopaque length: 3 or 40 cm Outside diameter: 0.014" Tip Outside diameter: 0.014" Coating: Hydrophilic or phobic Tip style: Shaping Ribbon Polymer cover: none Core Material: ELASTINITE Nitinol
  114. 114. TIP DESIGN  CORE TO TIP  SHAPING BALLOON
  115. 115. GUIDEWIRES FOR CTO
  116. 116. Core - to - tip Shaping ribbon
  117. 117. CTO Wire properties (1)Tip load Floppy wires <1g CTO Wires >3g
  118. 118. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  119. 119. CTO Wires (Stiffer) Non-coated / Hydrophobic TIP Non-tapered Tapered Miracle 3,4.5,6 Cross It 100 - 400 Hydrophilic TIP Non-tapered Pilot 50,100,150 Tapered Conquest Pro
  120. 120. Tapered wires Pros:  Minimizes tip resistance and  Select small vascular micro-channels within the CTO. Cons  These needle like tips can also easily dissect and perforate the vessel wall.
  121. 121. CTO guide wire techniques
  122. 122. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  123. 123. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  124. 124. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” Most CTOs with discrete entry point after initial attempt with soft (intermediate wires) Stiff , hydrophobic non-tapered wires
  125. 125. Lesion specific CTO approaches DRILLING (controlled) “Workhorse technique” • Miracle 3, 4.5, 6 • Cross It 100, 200, 300 • Medtronic Persuader 3,6 gm Stiff , hydrophobic non-tapered wires
  126. 126. Lesion specific CTO approaches Penetration • Blunt entry point • Heavily calcific or resistant lesions • Alternative to “drilling” as the “work horse technique” after initial soft wire failure Super stiff tapered wires
  127. 127. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  128. 128. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  129. 129. Core - to - tip Shaping ribbon
  130. 130. Any wire can perforate
  131. 131. Core characteristics  Core diameter Larger diameters improve the support. Lesser diameter more flexibility. Larger diameter – 1:1 torquability.  Core taper Shorter taper enhance the support and transmission of push force. Longer tapers enhance the flexibility.
  132. 132. “Support”  Indicator of the core strength  More stronger the core – more support
  133. 133. REFERNCES  JACC INTERVENTIONS APRIL2012  PCR-EAPCI TEXT BOOK
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