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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
 CLASSIFICATION
 PROPERTIES OF AN IDEAL 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 the stiffest part of the wire that gives the
stability and steerability to the guide wire.
CORE MATERIALS
 Stainless steel (Majority) /
 Nitinol (BMW)
 Tru-torque SS(Asahi), Durasteel (Galeo).

Dual Core – Nitinol + Stainless steel


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.
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
• Asahi Standard
• Asahi Prowater Flex
• Choice Floppy
• Luge
• IQ
• Forte Floppy
• Runthrough NS
• Galeo
How to test
guidewire
support



 Test method: measure the force
required for 60° bending at
different distances from the tip
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 to be used
 operator's experience and preference.
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)
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
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.
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..
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)
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
 WIGGLE WIRE
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-tapered
Pilot 50,100,150

Tapered
Conquest Pro
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 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.
THANK YOU
Lesion specific CTO approaches

SLIDING

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

Hydrophilic wires
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 initial attempt

with soft (intermediate wires)

Stiff , hydrophobic
non-tapered wires
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
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
Lesion specific CTO approaches

Penetration

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

Super stiff
tapered wires
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 - 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
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 across the
lesion, helping the wire negotiate tortuous anatomy,
— To improve deliverability by facilitating the
movement of interventional equipment over the wire.
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.
 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.
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 - 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
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
Non-tapered
Pilot 50,100,150

Tapered
Conquest Pro
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.
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 wires
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 initial attempt

with soft (intermediate wires)

Stiff , hydrophobic
non-tapered wires
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
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
Lesion specific CTO approaches

Penetration

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

Super stiff
tapered wires
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.
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.
 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.
 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
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.
Biomed Tech 2012; 57 (Suppl. 1) ©
2012
 CLASSIFICATION
 PROPERTIES OF AN IDEAL WIRE
 COMPONENTS OF A GUIDE WIRE
 WORKHORSE WIRE

 WIRES FOR SPECIAL OCCASIONS
 TRACKABILITY
stent
delivery systems
stent
delivery systems
 friction properties and flexibility of the stent system
 constitution of the vessel
 properties of the guide wire
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"
Coating: Hydrophilic or phobic
Tip style: Shaping Ribbon
Polymer cover: none
Core Material:
ELASTINITE Nitinol
 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.
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 wire performance.
 Almost all wires have a proximal PTFE coating.
 “True coating”

Distal tip – 30 cm
 To reduce friction
 To increase maneuverability
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
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.
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.
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.
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.
 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.
 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
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
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.
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.
• Impossible to perform
independent movements of the

wire and balloon.
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.
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 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
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.
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 (stiffer) wires

Tapered tip wires
Tapered and hydrophilic tip
 Always exchange the stiff wire for a soft

wire once crossed
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 to guide wire tip, for
turn-for-turn torque response.
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.
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)
 TIP STYLE
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
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
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
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
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
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,
Thank you
Thank you
 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.
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 stent
delivery systems
system
 constitution of the vessel
 properties of the guide wire
 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
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
Non-tapered
Pilot 50,100,150

Tapered
Conquest Pro
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.
CTO guide wire techniques
Lesion specific CTO approaches
SLIDING

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

Hydrophilic wires
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 initial attempt

with soft (intermediate wires)

Stiff , hydrophobic
non-tapered wires
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
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
Lesion specific CTO approaches

Penetration

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

Super stiff
tapered wires
(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 diameter – 1:1 torquability.

 Core taper
Shorter taper enhance the support and transmission of push force.

Longer tapers enhance the flexibility.
“Support”
 Indicator of the core strength
 More stronger the core – more support
REFERNCES
 JACC INTERVENTIONS APRIL2012
 PCR-EAPCI TEXT BOOK

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Choice And Use Of Appropriate Guidewire in PCI

  • 1. CHOICE AND USE OF APPROPRIATE GUIDEWIRE IN PCI SAJY KURUTTUKULAM
  • 2. CONTENTS  COMPONENTS OF A GUIDE WIRE  WORKHORSE WIRE  WIRES FOR DIFFERENT OCCASIONS  TRACKABILITY  KNOW YOUR WIRE  CLASSIFICATION  PROPERTIES OF AN IDEAL WIRE
  • 3. COMPONENTS OF A WIRE core,  distal tip and  outer covering.
  • 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. CORE MATERIALS  Stainless steel (Majority) /  Nitinol (BMW)  Tru-torque SS(Asahi), Durasteel (Galeo). Dual Core – Nitinol + Stainless steel 
  • 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. CORE-MATERIALS  NITINOL Excellent flexibility, steering Kink resistant  Negative Less torqueability than SS
  • 8.
  • 9. 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
  • 10.
  • 11. How to test guidewire support   Test method: measure the force required for 60° bending at different distances from the tip
  • 12. CTO Wire properties (1)Tip load Floppy wires <1g CTO Wires >3g
  • 13. The selection of a guidewire  essential component  INFLUENCED BY  vessel anatomy  the lesion morphology  the devices to be used  operator's experience and preference.
  • 14. 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)
  • 15. 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
  • 16. 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.
  • 17. 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..
  • 18. 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)
  • 20.
  • 21. TORTUOUS ANATOMY  very floppy wire with support for device delivery could be used  BMW  FIELDER FC  WHISPER ES  WIGGLE WIRE
  • 22.
  • 24.
  • 25.
  • 26. Tip load and support for Asahi Intecc guidewires
  • 27.
  • 28. 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
  • 29.
  • 30.
  • 31.
  • 32. CTO GUIDE WIRE TECNIQUES
  • 33.
  • 34. 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.
  • 35.
  • 36.
  • 37.
  • 39.
  • 40.
  • 41. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  • 42. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  • 47.
  • 48. WHICH WIRE WILL NOT PERFORATE
  • 49. ANY WIRE WILL PERFORATE
  • 50.
  • 52. Tip load and support for Asahi Intecc guidewires
  • 53. 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
  • 54.
  • 55. HOW TO CLASSIFY CORONARY GUIDE WIRES?
  • 56. CLASSIFICATION  NO UNIFORM CLASSIFICATION  BUT SOME CATEGORISATION
  • 57.
  • 58.
  • 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. 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.  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.
  • 63.
  • 64.
  • 65.
  • 66.
  • 67. SPECIFIC PURPOSE WIRES  PRESSURE WIRE  MARKER WIRE  ROTABLATOR WIRE  WIGGLE WIRE
  • 68.
  • 69. “Support”  Indicator of the core strength  More stronger the core – more support
  • 71.
  • 72. 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
  • 73.
  • 74. Pseudostenosis caused by wire in tortuous vessel
  • 75.
  • 76.
  • 77.
  • 79.
  • 80. Core - to - tip Shaping ribbon
  • 81.
  • 82. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  • 83. 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
  • 84. 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.
  • 85.
  • 86.
  • 87.
  • 88.
  • 89. CTO guide wire techniques
  • 90. Tip load and support for Asahi Intecc guidewires
  • 91. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  • 92. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  • 93. 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
  • 94. 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
  • 95. 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
  • 96. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  • 97.
  • 98.
  • 99.
  • 100.
  • 101.
  • 102.
  • 103.
  • 104. 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.
  • 105. 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.
  • 106.  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.
  • 107.  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
  • 108. 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.
  • 109. Biomed Tech 2012; 57 (Suppl. 1) © 2012
  • 110.
  • 111.
  • 112.
  • 113.  CLASSIFICATION  PROPERTIES OF AN IDEAL WIRE  COMPONENTS OF A GUIDE WIRE  WORKHORSE WIRE  WIRES FOR SPECIAL OCCASIONS  TRACKABILITY
  • 114.
  • 115.
  • 117. stent delivery systems  friction properties and flexibility of the stent system  constitution of the vessel  properties of the guide wire
  • 118.
  • 119. Biomed Tech 2012; 57 (Suppl. 1) © 2012
  • 120.  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
  • 121.
  • 122.  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.
  • 123.
  • 124. Any wire can perforate
  • 125.
  • 127. 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
  • 128.
  • 129. 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
  • 130. 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.
  • 131. 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.
  • 132. 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.
  • 133. 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.
  • 134.  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.
  • 135.  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
  • 136. 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
  • 137. 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.
  • 138.
  • 139.
  • 141. 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.
  • 142. 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.
  • 144. Wire tip  Wire tip – important component.  Decides the wire characteristics  CTO Wires
  • 145. 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
  • 146. 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.
  • 149. BOSTON Forté® Floppy Marker Wire Tip Radiopacity: 2cm; two 5mm marker system
  • 150. enhanced precision and control turn-for-turn torque response.
  • 151. 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
  • 152.
  • 153.
  • 154.
  • 155. Side branch at CTO 1. Hydrophilic wires may not succeed. 2.Careful penetration to enter the plaque.
  • 156. 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.
  • 157.
  • 158.
  • 159. 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.
  • 161. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING
  • 162. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)
  • 163. CATEGORISATION  TIP FLEXIBILITY(floppy/soft, intermediate, stiff),  TIP COATING(hydrophilic hydrophobic, No coating)  TIP STYLE
  • 164. 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
  • 165. 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
  • 166. 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
  • 167. 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
  • 168. 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
  • 169. 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,
  • 171.
  • 172.
  • 173.  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.
  • 174. Components of a guide wire  Core  Outer covering  Distal tip
  • 175. The effect of different guide wires on the trackability of coronary stent delivery systems
  • 176. 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
  • 177.
  • 178.  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
  • 179.
  • 180. TIP DESIGN  CORE TO TIP  SHAPING BALLOON
  • 182.
  • 183. Core - to - tip Shaping ribbon
  • 184.
  • 185. CTO Wire properties (1)Tip load Floppy wires <1g CTO Wires >3g
  • 186. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  • 187. 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
  • 188. 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.
  • 189.
  • 190.
  • 191.
  • 192.
  • 193. CTO guide wire techniques
  • 194. Lesion specific CTO approaches SLIDING  Micro-channels present  ISR total occlusions  STAR technique Hydrophilic wires
  • 195. Lesion specific CTO approaches SLIDING • Pilot, Whisper • Fielder wires • Cordis – Shinobi Hydrophilic wires
  • 196. 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
  • 197. 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
  • 198. 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
  • 199. Lesion specific CTO approaches Penetration Asahi Conquest (regular) and Pro Cross It 400 Persuader 9 gm Super stiff tapered wires
  • 200.
  • 201.
  • 202. (2) Hydrophilic coating - Slippery (3) Tapering of wire tip.
  • 203.
  • 204.
  • 205. Core - to - tip Shaping ribbon
  • 206. Any wire can perforate
  • 207. 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.
  • 208. “Support”  Indicator of the core strength  More stronger the core – more support
  • 209. REFERNCES  JACC INTERVENTIONS APRIL2012  PCR-EAPCI TEXT BOOK