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CORONARY GUIDEWIRES
CHOICE & APPROPRIATE USE IN PCI
Dr Vallabhaneni Sri Ram Bhupal
NIMS,Hyderabad,India
CONTENTS
• COMPONENTS OF A GUIDE WIRE
• CLASSIFICATION
• WIRES FOR DIFFERENT OCCASIONS
• GUIDEWIRE MANIPULATION
• COMPLICA...
•GRUNTZIG First performed Angioplasty in 1974
•1977 – First coronary angioplasty
•Polyvinyl Chloride balloon catheter with...
•1982 – Simpson reported
First experience with over
the balloon system
•It had an independently
movable guidewire within
t...
• To reach far end of the vessel
• To rail the devices into coronaries
• To access the lesion
• To cross the lesion atraum...
4 KEY characteristics
1. Torque control
Is an ability to apply rotational force at a proximal end of a guidewire and have
...
Other features
5. Prolapse tendency
Tendency of the body of a wire not to follow the tip around bends
6. Radiopacity/visib...
STRUCTURE
 CORE-Material
Diameter
Core taper
 TIP
 COILS, COVERS & COATINGS
Core
• Inner part of the guidewire
• Extends through the shaft of the wire from the
proximal to the distal part
• Distal t...
Core Material
Core material affects the flexibility, support, steering
and trackability
• Stainless steel
– superior torqu...
Core Diameter
• Influences the performance of the wire
• Larger diameter improves support and allows 1:1
torque response
•...
Tip
• Tapers distally to a variable extent
– 2-piece core- distal part of core does not reach
distal tip of wire→ shaping ...
Coils, Covers & Coating
Keeps the diameter at .014 inch
• Coils
– Stainless steel
– Outer coil Design – Coils placed over ...
Coils
Radio-opaque tip
• Visibility of the wire tip is provided by radiopaque
platinum coils that are usually placed at the dist...
• Covers
– Polymer or plastic
– Lubricity
• Coating
– Distal half
– Affects lubricity and tracking
– Creates tactile feel
...
Non-Coated / Hydrophobic wires
Pros
• More controllable (and therefore less likely to dissect)
• Provide better tactile fe...
• Hydrophobic coatings are silicone based
coatings which repel water and are applied on
the working length of the wire, wi...
Hydrophilic
• Applied over the entire working length of wire
including tip coils
• Attracts water - needs lubrication
• Th...
Shapeability and shaping memory
• Shapeability - allows to modify its distal tip
conformation
• Shaping memory - ability o...
HOW TO CLASSIFY CORONARY
GUIDE WIRES?
CLASSIFICATION
• NO UNIFORM CLASSIFICATION
• BUT SOME CATEGORISATION
Classification
Based on Tip Flexibility
• Floppy – Eg:- Hi torque balance middle weight, Hi
torque balance,Choice floppy
•...
“Support”
• Indicator of the core strength
• More stronger the core – more support
Floppy
ES – Extra-Support
Grand-Slam
Iron-man
Based on coating
• Hydrophilic : Eg:- CholCETM PT Floppy
• Hydrophobic : Eg:- Asahi soft
Depending on tip load
• Floppy, B...
BASED ON CLINICAL SCENARIO
Commonly Used Workhorse
Guidewires
• ATW/ATW Marker
• Stabilizer
• BMW / BMW Universal
• Zinger
• Cougar XT
• Asahi Light ...
Balance Middleweight Universal wire
(Abbott Vascular/Guidant, Santa Clara, CA)
• Quite steerable - tip is suitable for ben...
CHOICE FLOPPY
SELECTION OF GUIDEWIRES FOR
SPECIAL LESIONS
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...
BIFURCATION PCI
• In the presence of difficulties accessing the
side branch some hydrophilic wires such as
the ChoICE™ PT ...
• These wires have higher risk to perforate the
distal vessel if allowed to migrate into small
side branches or too distal...
MAIN VESSEL
TRACKING
Short tapering
better
DISSECTIONS
• ChOICE Floppy
• Asahi Soft .
• The parallel wire technique can be
recommended if a dissection plane is enter...
CALCIFIED LESIONS
• ChoICE Floppy (Boston Scientific).
• If it fails to cross the lesion, the next step is to
choose flopp...
TORTUOUS ANATOMY
• Very floppy wire with support for device
delivery could be used
• BMW
• FIELDER FC
• WHISPER ES
• WIGGL...
CTO WIRES
CLASSIFICATION OF CTO WIRES
CTO guide wire techniques
Lesion specific CTO approaches
SLIDING
 Micro-channels present
 CTO’s < 6 months
 ISR total occlusions
 STAR technique...
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
entry point after initi...
Lesion specific CTO approaches
Penetration
• Blunt entry point
• Heavily calcific or resistant lesions
• Alternative to “d...
GUIDEWIRES FOR RETROGRADE
TECHNIQUES
– Fielder/FielderFC
– X -treme
– Whisper
– ChoICE PT2
– Runthrough / Runthrough Hyper...
COMMONLY USED CTO WIRES
Fielder™ / Fielder FC™ (Asahi Intec Co.)
• Special guidewire - distal coil coated with
polymer sleeve & further coated wit...
Whisper
• Durasteel™ Core-to-tip designed to improve
steering, durable shape retention and tactile
feedback
• Full Polymer...
SUMMARY OF WIRES
WORKHORSE WIRES
EXTRA SUPPORT WIRES
CTO WIRES
Guidewire Manipulations
• Two step process
• Shaping the wire tip
– It minimizes the amount of force applied to the
wire
–...
Shaping the Wire Tip
Steering of the wire
• Small alternating rotations to left and right
• Excessive rotations should be avoided to
prevent wi...
Optimum guide wire positioning
• Should be placed as distally as possible in the
target vessel
• Allows extra support when...
Strategies if Guidewire fails to cross
• Make the guide more coaxial with the lumen
of the artery
• Use a balloon to direc...
Complications
• Vessel perforations
– Uncommon <1%
– Risk factors
• Hydrophilic wires, core to tip
• Chronic total occlusi...
–Classification
• Type I – Extraluminal crater without extravasation
• Type II – Containing pericardial or myocardial
blus...
Pseudolesions/Concertina effect
• Stenosis that appears in any artery after the coronary
guidewire is placed in the artery...
Diagnosis
• Will disappear if the wire is withdrawn
• Replacement of a stiff wire with a flexible floppy
wire eliminates p...
Guidewire Entrapment
Factors
• Presence of calcified vessels (Eg:- RCA)
• Repeated use of wire for multiple interventions
...
Management
• Advance a small profile balloon or a small caliber
catheter (transit catheter) to the attachment site
and pul...
Guidewire fracture and Embolization
• Risk factors are calcified lesion, bifurcation
stenting and prolonged procedures
• M...
THANK YOU
Husband must obey wife but not reverse
• Operator is husband until his guide wire is not
in coronary artery but then you k...
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
Coronary guidewires
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Coronary guidewires

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Coronary guidewires

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Coronary guidewires

  1. 1. CORONARY GUIDEWIRES CHOICE & APPROPRIATE USE IN PCI Dr Vallabhaneni Sri Ram Bhupal NIMS,Hyderabad,India
  2. 2. CONTENTS • COMPONENTS OF A GUIDE WIRE • CLASSIFICATION • WIRES FOR DIFFERENT OCCASIONS • GUIDEWIRE MANIPULATION • COMPLICATIONS
  3. 3. •GRUNTZIG First performed Angioplasty in 1974 •1977 – First coronary angioplasty •Polyvinyl Chloride balloon catheter with short guidewire attached to its tip
  4. 4. •1982 – Simpson reported First experience with over the balloon system •It had an independently movable guidewire within the balloon dilation catheter
  5. 5. • To reach far end of the vessel • To rail the devices into coronaries • To access the lesion • To cross the lesion atraumatically • To provide support for interventional devices
  6. 6. 4 KEY characteristics 1. Torque control Is an ability to apply rotational force at a proximal end of a guidewire and have that force transmitted efficiently to achieve proper control at the distal end 2. Trackability Is an ability of a wire to follow the wire tip around curves and bends without bucking or kinking, to navigate anatomy of vasculature 3. Steerability Is an ability of a guidewire tip to be delivered to the desired position in a vessel 4. Flexibility Is an ability to bend with direct pressure
  7. 7. Other features 5. Prolapse tendency Tendency of the body of a wire not to follow the tip around bends 6. Radiopacity/visibility Is an ability to visualise a guidewire or guidewire tip under fluoroscopy. 7. Tactile feedback Is tactile sensation on a proximal end of a guide wire that physician has that tells him what the distal end of the guidewire is doing 8. Crossing Is an ability of a guidewire to cross lesion with little or no resistance 9. Support Is an ability of a guidewire to support a passage of another device or system over it
  8. 8. STRUCTURE  CORE-Material Diameter Core taper  TIP  COILS, COVERS & COATINGS
  9. 9. Core • Inner part of the guidewire • Extends through the shaft of the wire from the proximal to the distal part • Distal taper • Stiffest part of the wire that gives stability and steerability
  10. 10. Core Material Core material affects the flexibility, support, steering and trackability • Stainless steel – superior torque characteristics, can deliver more push, provides good shapeability and excellent support – more susceptible to kinking and is less flexible • Nitinol – pliable but supportive, less torquability than SS – generally considered kink resistant & have a tendency to return to their original shape, making them potentially less susceptible to deformation during prolonged use
  11. 11. Core Diameter • Influences the performance of the wire • Larger diameter improves support and allows 1:1 torque response • Smaller diameter enhances the flexibility Core taper • Variable length • Continuous/segmented • Short taper and smaller number of wide spaces gradual tapers increases support and transmission of push force • Longer tapers and larger numbers of segmented tapering increases flexibility
  12. 12. Tip • Tapers distally to a variable extent – 2-piece core- distal part of core does not reach distal tip of wire→ shaping ribbon, extends to distal tip – 1-piece core- tapered core reaches distal tip. • 2-piece→ easy shaping & durable shape memory • 1-piece →better force transmission to tip & greater “tactile response” for operator
  13. 13. Coils, Covers & Coating Keeps the diameter at .014 inch • Coils – Stainless steel – Outer coil Design – Coils placed over tapered core and tip of the wire – Tip coil Design – Tip alone is covered with coils – Flexibility, support, steering, tracking, visibility & tactile feedback – Radio opaque platinum coils – Intermediate coils placed on the working length of the wire
  14. 14. Coils
  15. 15. 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
  16. 16. • Covers – Polymer or plastic – Lubricity • Coating – Distal half – Affects lubricity and tracking – Creates tactile feel – Reduces friction – Facilitates movement of wire within the vessel and deliverability of intervention equipment
  17. 17. 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.
  18. 18. • 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 "wax-like" 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.
  19. 19. Hydrophilic • Applied over the entire working length of wire including tip coils • Attracts water - needs lubrication • Thin, non slippery, solid when dry→ becomes a gel when wet – ↓friction – ↑trackability – ↓Thrombogenic ↓tactile feel- ↑risk of perforation Tendency to stick to angioplasty cath • Useful in negotiating tortuous lesions and in “finding microchannels” in total occlusions
  20. 20. Shapeability and shaping memory • Shapeability - allows to modify its distal tip conformation • Shaping memory - ability of tip to return back to its basal conformation after having been exposed to deformation & stress – Both do not necessarily go in parallel – SS core wires -easier to shape (↑memory- nitinol core) – 2-piece core + shaping ribbon - easier to shape & ↑memory
  21. 21. HOW TO CLASSIFY CORONARY GUIDE WIRES?
  22. 22. CLASSIFICATION • NO UNIFORM CLASSIFICATION • BUT SOME CATEGORISATION
  23. 23. Classification Based on Tip Flexibility • Floppy – Eg:- Hi torque balance middle weight, Hi torque balance,Choice floppy • Intermediate – Eg:- Hi torque intermediate, Choice intermediate • Standard – Shinobi, Boston Scientific Based on Device support • Light – Eg:- Hi torque balance • Moderate – Eg:- Hi torque balance middle Weight • Extra support – Eg:- Hi torque whisper,Choice
  24. 24. “Support” • Indicator of the core strength • More stronger the core – more support
  25. 25. Floppy ES – Extra-Support Grand-Slam Iron-man
  26. 26. Based on coating • Hydrophilic : Eg:- CholCETM PT Floppy • Hydrophobic : Eg:- Asahi soft Depending on tip load • Floppy, Balanced & Extra support • Tip load - force needed to bend a wire when exerted on a straight guide wire tip, at 1 cm from the tip – Floppy - <0.5g – Balanced – 0.5-0.9g – Extra support - >0.9g
  27. 27. BASED ON CLINICAL SCENARIO
  28. 28. Commonly Used 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
  29. 29. Balance Middleweight Universal wire (Abbott Vascular/Guidant, Santa Clara, CA) • Quite steerable - tip is suitable for bending in a “J” configuration for distal advancement into the distal vessel bed with minimal trauma while still maintaining some torque • shape retention relatively poor -any J configuration tends to become magnified over time → consequent loss in steerability • moderately torquable- progression - minimal friction (light hydrophilic coating) - Dye injection may also be helpful to propagate distal advancement • suitable for rapid, uncomplicated interventions • low risk to cause dissections/distal perforations • support - low to moderate
  30. 30. CHOICE FLOPPY
  31. 31. SELECTION OF GUIDEWIRES FOR SPECIAL LESIONS
  32. 32. The selection of a guidewire • Essential component • INFLUENCED BY • vessel anatomy • the lesion morphology • the devices to be used • operator's experience and preference.
  33. 33. 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
  34. 34. 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.
  35. 35. • These wires have higher risk to perforate the distal vessel if allowed to migrate into small side branches 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.
  36. 36. MAIN VESSEL TRACKING Short tapering better
  37. 37. 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..
  38. 38. 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)
  39. 39. TORTUOUS ANATOMY • Very floppy wire with support for device delivery could be used • BMW • FIELDER FC • WHISPER ES • WIGGLE WIRE
  40. 40. CTO WIRES
  41. 41. CLASSIFICATION OF CTO WIRES
  42. 42. CTO guide wire techniques
  43. 43. Lesion specific CTO approaches SLIDING  Micro-channels present  CTO’s < 6 months  ISR total occlusions  STAR technique Hydrophilic wires Fielder,Crosswir eNT, HT Pilot, Whisper, Choice PT
  44. 44. 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 MiracleBros (3 g, 4.5 g and 6 g), Persuader (3 g and 6 g) and Cross-IT XT (100/200/300)
  45. 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 Conquest Pro (9 g, 12 g), Cross-IT XT 400, MiracleBros 12
  46. 46. GUIDEWIRES FOR RETROGRADE TECHNIQUES – Fielder/FielderFC – X -treme – Whisper – ChoICE PT2 – Runthrough / Runthrough Hypercoat
  47. 47. COMMONLY USED CTO WIRES
  48. 48. Fielder™ / Fielder FC™ (Asahi Intec Co.) • Special guidewire - distal coil coated with polymer sleeve & further coated with a hydrophilic coating • Provides advanced slip performance & trackability for highly stenosed lesion & tortuous vessels • Very good torque performance • Combines both slide and torque performance • Primary wire used in the retrograde technique of recanalization of CTO
  49. 49. Whisper • Durasteel™ Core-to-tip designed to improve steering, durable shape retention and tactile feedback • Full Polymer cover with Hydrophilic coating intended for deliverability and smooth lesion access • Responsease™ “transitionless” core grind designed to provide improved tracking and better torque response • Tip coils designed to provide softer, shapeable tip and also improve tactile feedback
  50. 50. SUMMARY OF WIRES
  51. 51. WORKHORSE WIRES
  52. 52. EXTRA SUPPORT WIRES
  53. 53. CTO WIRES
  54. 54. Guidewire Manipulations • Two step process • Shaping the wire tip – It minimizes the amount of force applied to the wire – For steering into the vessel – For visualization of torquing effort
  55. 55. Shaping the Wire Tip
  56. 56. Steering of the wire • Small alternating rotations to left and right • Excessive rotations should be avoided to prevent wire tip fracture
  57. 57. Optimum guide wire positioning • Should be placed as distally as possible in the target vessel • Allows extra support when crossing with balloon/stent catheters • ↓ chance of the wire becoming displaced backwards across the lesion and necessitating re-crossing Avoid vessel perforation when positioning wires with hydrophilic coatings very distally
  58. 58. Strategies if Guidewire fails to cross • Make the guide more coaxial with the lumen of the artery • Use a balloon to direct the wire • Modify the bend at the tip of the wire • Change the wire
  59. 59. Complications • Vessel perforations – Uncommon <1% – Risk factors • Hydrophilic wires, core to tip • Chronic total occlusions – Diagnosis • Angiographic diagnosis • Small extraluminal extravasation of blush in the distribution of target vessel • Emergency echo to r/o pericardial effusion and tamponade – Prognosis • Extend of extravasation into pericardium
  60. 60. –Classification • Type I – Extraluminal crater without extravasation • Type II – Containing pericardial or myocardial blushing • Type III - having≥ 1 mm diameter with contrast streaming: and cavity spilling –Management • Reversal of anticoagulations • Prolonged balloon inflation • PTFE covered stent • Coil embolization • Use of gel foams
  61. 61. Pseudolesions/Concertina effect • Stenosis that appears in any artery after the coronary guidewire is placed in the artery • Appears in tortuous vessels that have been straightened out by the guidewire
  62. 62. Diagnosis • Will disappear if the wire is withdrawn • Replacement of a stiff wire with a flexible floppy wire eliminates pseudolesion • Microcatheter or a balloon catheter can be placed distal to the lesion Complications • In some cases cause hemodynamic compromise and ischemia
  63. 63. Guidewire Entrapment Factors • Presence of calcified vessels (Eg:- RCA) • Repeated use of wire for multiple interventions • Repeated attempts at crossing the same lesion multiple times with the same wire • Two wires my become entrapped when the “Buddy wire” technique is used • Crossing fresh stent struts
  64. 64. Management • Advance a small profile balloon or a small caliber catheter (transit catheter) to the attachment site and pull back gently • When a second or “buddy wire” gets trapped between a stent and the vessel wall gentle traction can be used • Surgery
  65. 65. Guidewire fracture and Embolization • Risk factors are calcified lesion, bifurcation stenting and prolonged procedures • Management – Surgery – Snaring the Embolized wire fragment • The Amplatz Gooseneck Microsnare • The EnSnare Triple Loop Device • The X Pro Micro Elite Snare • The Alligator Retrieval Device – Push and paste
  66. 66. THANK YOU
  67. 67. Husband must obey wife but not reverse • Operator is husband until his guide wire is not in coronary artery but then you know …..

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