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![Relation of tip load and penetration force
73
0 100 200 300 400 500 600 700 800 900 1000
Gaia Next 3
Gaia 3rd
Conquest Pro
Miracle 12
Conquest Pro 8-20
Conqeust Pro 12
Penetration force [gf/mm2]
0 5 10 15 20 25
Gaia Next 3
Gaia 3rd
Conquest Pro
Miracle 12
Conquest Pro 8-20
Conqeust Pro 12
Tip load](https://image.slidesharecdn.com/wireselectioneuroctoclub2018-180919091044/75/CTO-fundamental-Understanding-of-Wire-Structure-65-2048.jpg)
![0.0
200.0
400.0
2 5 10 15 20 25 30
Gaia Third Gaia next 3rd
Conquest Pro Conquest Pro12
Conquest Pro8-20 Miracle 12
74
Stiff
- Tip flexibility
[mm]
Guide wire
[mN]](https://image.slidesharecdn.com/wireselectioneuroctoclub2018-180919091044/75/CTO-fundamental-Understanding-of-Wire-Structure-66-2048.jpg)
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CTO fundamental: Understanding of Wire Structure
- 1. CTO Fundamental: Understanding ofWire Structure For appropriate GW selection and exchange Etsuo Tsuchikane, MD, PhD Toyohashi Heart center, Japan Toyohashi Heart CenterEURO CTO CLUB Toulouse 2018
- 2. Becoming a CTOexpert In order to become a CTO expert, it is essential to understand the fundamentals of guide wires – Basic structure – Attributes and performance – New technologies – Optimization of guide wires
- 3. Guide wire basicstructure Conventional guide wire Outer coil Core wire
- 4. ASAHI’s composite guidewire definition ASAHI’s composite guide wire Products developed with ASAHI’s composite technology Guide wire that is composed of more than “core wire” and “outer coil”
- 5. Primary wire Name Definition/ Explanation Illustration image Flexibility Wire Single wire + Wire rope Wire rope made of several single wires that are roped together + + Primary wire Single wire Single wire ropeFlexibility < * When it has same outer diameter
- 6. 1 2 34 5 … 1 2 3 4 5 … 1 2 3 4 5 .. 1 2 3 4 5 … 1 2 3 4 5 … 1 2 3 4 5 .. Coil formation image Primary Wire Wire Wire rope Coil formation XTRAND Single wire coil Multi wire coil ACT ONE Multi wire rope coil Single wire rope coil Note: ACT ONE is placed inside guide wires, and the direction of the coil strand is different. ※The standing direction of this image does not matter
- 7. Guide wire basicstructure – Difference in the core Round core and conventional flat core design Avoid whipping phenomenon Conventional flat core Better maneuverability even in complex vessel anatomy Round core ✔ Whip motion depends on core wire design stress high low
- 8. Challenges to overcomethe trade-off Torque forceFlexibility Trade-off No compromise of flexibility or torque force
- 9. Composite guide wirestructure Composite guide wire Outer coil Core wire (round / flat) ACT ONE (inner coil) Twist wire (runs parallel to the core wire)
- 10. Composite guide wirecomponents New technology that overcomes the trade-off: Composite guide wire Enhances the guide wire’s tensile strength One to one torque Original guide wire components Outer coil Core wire ACT ONE Twist wire Multi wire coil Provides torque force, torque response, durability and flexibility
- 11. • Applying ASAHIINTECC’s unique wire forming technology, we developed drawing technology and torque technology : • Multi wire coil • Enhances torque force, torque response, durability and flexibility ACT ONE: ASAHI brand multi wire coil provides torque force, torque response, durability and flexibility. ACT ONE While keeping torque response and force, the guide wire still maintains softness due to the addition of ACT ONE. New technology that overcomes the trade-off : ACT ONE
- 12. The above datawas obtained by company standardized test, which may differ from industry standardized tests. The above data does not prove that all devices have exactly the same performance with the samples used for these tests. Conventional coil (single wire coil) ACT ONE (Multi wire coil) Same torque force input by hand, but different output at the wire tip. * ACT ONE *Compared to our company’s coil New technology that overcomes the trade-off: ACT ONE
- 13. ✔ Wires havethe same OD, but the twist wire is more flexible ✔ Twist wire offers better tensile strength Keeps tensile strength while maintaining flexibility. Wire rope Single wire Only in the structure of SION, SION blue, SION black and SUOH 03 *View from side *View from front Twist wire New technology that overcomes the trade-off : Twist wire
- 14. Difference in corestructure Conventional guide wires ASAHI Gaia series ASAHI Gaia Next series Fielder XT-A Fielder XT-R SION SION blue SION black SUOH 03 * ACT ONE × ● ACT ONE is placed next to the distal tip or away from distal tip depending on the product. ● Twist wire × × ● * SUOH 03 has a unique core structure :“no core wire to the ball tip”.
- 15. Terminology & Definitionsummary <Primary wires & Coils> Primary wire Coil formation (General name) Coil name (ASAHI original name) Picture Wire type Amount of wires Wire Single Single wire coil Multi Multi wire coil ACT ONE construction Wire rope Single Single wire rope coil Multi Multi wire rope coil XTRAND
- 16. Benefit of eachcoil Definition and name Flexibility Torque force Single wire coil i.x) Same as the outer coil of conventional guide wires 2nd 3rd Multi wire coil i.x) Same as the inner coil, ACT ONE, in composite guide wires 4th 1st Single wire rope coil i.x) Same as the outer coil of SUOH 03 1st 4th Multi wire rope coil i.x) Same as the outer coil of Gaia Next 3rd 2nd Ranking shows the comparison of 4 kinds of coils with 2 different features Condition: Outer diameter of the primary wire (wire / wire rope) is the same. Same amount of wires in multiple numbers.
- 17. Penetration efficacy a. Tipload (~ 10mm) b. Tip cross section area • Tip end design Plain ball tip / Micro cone tip / Blunt tip c. Tip flexibility (~ 30mm) d. Tip lubricity i. Hydrophilic on Polymer jacket ii. Hydrophilic ( Hi / Low) iii. Silicone The factor that is necessary to penetrate a lesion Key factor of CTO Guide Wire Penetration force
- 18. The ball tiphas been sharpened to provide the necessary penetration ability to enter hard occlusions, while the tip flexibility is still maintained. Tip end design / Cross section area Blunt tip Plain ball tip Micro-cone tip --- Conventional guidewire --- Gaia, Gaia Next --- Miracle Neo 3 Gaia Second Conquest Pro Tip end design Cross section area
- 19. Micro-cone tip vs.plain ball tip Difference of penetration ability at CTO entry Gaia Next 1 Plain ball tipMicro-cone tip Tentative model for test Tentative model of Gaia Next 1 with plain ball tip failed to enter the lesion as the tip could not stick onto the diagonal entry ETOSS model Tip end design CTO entry×
- 20. Gaia Next 3 withMicro cone tip Miracle 6 with plain ball tip Miracle 6 vs. Gaia Next 3 (ETOSS 6000) CTO body×Tip end design Although these two have the same tip load, they show different movement when trying to change routes within the CTO body. It was easy to re-direct GN3 as the sharp micro cone tip caught easily on the space wall, then changed direction using deflection created by the wire .
- 21. Penetration efficacy a. Tipload (~ 10mm) b. Tip cross section area • Tip end design Plain ball tip / Micro cone tip / Blunt tip c. Tip flexibility (~ 30mm) d. Tip lubricity i. Hydrophilic on Polymer jacket ii. Hydrophilic ( Hi / Low) iii. Silicone The factor that is necessary to penetrate a lesion Key factor of CTO Guide Wire Penetration force
- 22. A greater tipflexibility results in a greater occurrence of deflection within the lesion Tip flexibility 30 mm Non-tapered tip Reference Tip end Tip (30 mm) Tapered tip Tapered tip 30 mm
- 23. Lesion diameter 4mmvs 6mm with XT-A (ETOSS 8000) Tip flexibility CTO entry× 25 mm 25 mmXT-A: Lesion diameter: 6mm XT-A: Lesion diameter: 4mm It is more difficult for flexible wires to penetrate the CTO entry when there is a bigger open space. Push force could not be transmitted to the tip due to loss of force because the tip was bent severely.
- 24. Gaia ThirdGaia SecondConquest Pro Branch ostial CTO (ETOSS 2 layers: 6000/10000) Tip flexibility CTO entry ⇒ body× It is obvious that the push force of Gaia Second from the tip to the bifurcation entry was insufficient to penetrate and the tip easily got prolapsed even after it hooked at entry site. The other two guidewires were able to hook at the entry to make penetration.
- 25. Penetration efficacy a. Tipload (~ 10mm) b. Tip cross section area • Tip end design Plain ball tip / Micro cone tip / Blunt tip c. Tip flexibility (~ 30mm) d. Tip lubricity i. Hydrophilic on Polymer jacket ii. Hydrophilic ( Hi / Low) iii. Silicone The factor that is necessary to penetrate a lesion Key factor of CTO Guide Wire Penetration force
- 26. High Silicone on Coil Hydrophilicon Coil Hydrophilic on Polymer jacket Lubricity for CTO wire
- 27. Lesion diameter：4 mm Withoutcoating vs. coating XT-A Abrupt and smooth entry (ETOSS 8000) Lubricity × CTO entry XT-A without coating XT-A In the case with abrupt and smooth lesion entry, XT-A, after wiping off the coating, could penetrate the lesion as the tip caught at the entry like a hook. However, it failed to go further due to heavy resistance because of the uncoated tip within the lesion. On the other hand, for conventional XT-A, it slipped and was not able to penetrate the lesion.
- 28. Abrupt and smoothAbrupt and rough XT-A: Abrupt and smooth / rough entry (ETOSS 8000) Lubricity × CTO entry In the case with abrupt and smooth entry, the tip of XT-A slipped and could not go into the lesion. But with the abrupt and rough entry, XT-A could penetrate the lesion by focusing the force onto a dimple even though the tip was slippery.
- 29. Coating vs withoutcoating Gaia Next 2 (ETOSS 10000) Lubricity × CTO body Gaia Next 2 Gaia Next 2 without coating When lubricity was lost in the CTO body, the longer the wire’s distance inside the body, the more difficult it was to advance due to increased sliding resistance.
- 30. Appropriate Guide Wire Selectionand Exchange Case Presentations
- 31. Case 1: RCACTO collateral from LAD apical channel
- 32. Case 1: Bilateralangiography
- 33. Case 1: Retrogradewiring; Corsair + XTR
- 34. Case 1: Retrogradewiring; SASUKE + XTA
- 35. Case 1: Retrogradewiring; SASUKE + UB3
- 36. Penetration efficacy a. Tipload (~ 10mm) ☛ 0.6f b. Tip cross section area ☛ Tip end design : Plain ball tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic with polymer Manipulation capability a. Torque force b. Torque response XT-R Asahi composite guide wire
- 37. Penetration efficacy a. Tipload (~ 10mm) ☛ 3.0gf b. Tip cross section area ☛ Tip end design : Plain ball tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response ULTIMATE bros3 Conventional structure guide wire
- 38. Next choice Penetration efficacy☛ ≥ ULTIMATE bros3 Tip load ☛ ≥ ULTIMATE bros3 Tip flexibility ☛ < ULTIMATE bros3 Tip lubricity ☛ ˃ ULTIMATE bros3 Manipulation capability ☛ ≥ ULTIMATE bros3 Torque force ☛ ≥ ULTIMATE bros3 Torque response ☛ > ULTIMATE bros3 46 Polymer Jacket GW
- 39. Penetration efficacy a. Tipload (~ 10mm) ☛ 4.0gf b. Tip cross section area ☛ Tip end design : plane ball tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic with polymer jacket Manipulation capability a. Torque force b. Torque response PILOT 200 Conventional structure guide wire
- 40. Case 1: SASUKE+ PILOT 200
- 41. XT-R / ULTIMATEbros3 / PILOT200 49
- 42. Case 2: RCAISO : Control angiography 50
- 43. Case 2: RCAISO Proximal lesion cross 51 GW : GAIA Next2 MC : Mogul Thinner GW : Gradius 14 MC : Finecross GT
- 44. Case 2: RCAISO 52 GW : Confianza Pro 8-20
- 45. 53 GW : ConfianzaPro 8-20 Case 2: RCA ISO
- 46. Penetration efficacy a. Tipload (~ 10mm) ☛ 20.0gf b. Tip cross section area ☛ Tip end design : Plane ball tip with tapered coil c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response Conventional structure guide wire with round core Confianza (Conquest) Pro 8-20 0.20mm (0.008inch) 0.36mm (0.014inch)
- 47. Penetration efficacy a. Tipload (~ 10mm) ☛ 12.0gf b. Tip cross section area ☛ Tip end design : Plane ball tip with tapered coil c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response Conventional structure guide wire with round core Confianza (Conquest) Pro 12
- 48. Differences between Confianza Pro12 and Pro 8-20
- 49. Next choice Penetration efficacy Tipload ☛ ≦ Confianza Pro 8-20 Tip flexibility ☛ ＞ Confianza Pro 8-20 Tip end design Tip lubricity Manipulation capability ☛ ≧ Confianza Pro 8-20 Torque force Torque response GAIA Next 3
- 50. Penetration efficacy a. Tipload (~ 10mm) ☛ 6.0gf b. Tip cross section area ☛ Tip end design : Micro cone tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response GAIA Next 3 ASAHI composite guide wire
- 51. Confianza Pro 8-20vs GAIA Next 3
- 52. ETOSS lesion :8000gf Guidewire : Confianza Pro 8-20 ETOSS lesion : 8000gf Guidewire : GAIA Next 3 Comparison of deflection Confianza Pro8-20 & GAIA Next 3
- 53. Case 2: RCAISO body re-route 61 GW : GAIA Next 3
- 54. Target : LAD#6 CTO Case 3
- 55. CTO body GAIANext 2 was selected for an initial wire, however the CTO entry could not be penetrated. So that GAIA Next 3 was selected as the second wire. 63
- 56. Target : LAD#6 CTO Case 3 GW : GAIA Next 3 MC : Corsair pro
- 57. Target : LAD#6 CTO Case 3 GW : GAIA Next3 MC : Corsair pro GW : GAIA Next 3 MC : Corsair pro
- 58. Target : LAD#6 CTO Case 3 GW : GAIA Next3 MC : Corsair pro GW : GAIA Next 3
- 59. Target : LAD#6 CTO Case 3 GW : GAIA Next 3 MC : Corsair pro
- 60. Target : LAD#6 CTO Case 3 GW : GAIA Next 3 MC : Corsair pro
- 61. Penetration efficacy a. Tipload (~ 10mm) ☛ 6.0gf b. Tip cross section area ☛ Tip end design : Micro cone tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response GAIA Next 3 ASAHI composite guide wire
- 62. Penetration efficacy a. Tipload (~ 10mm) ☛ 6.0gf b. Tip cross section area ☛ Tip end design : Micro cone tip c. Tip flexibility (~ 30mm) d. Tip lubricity ☛ Hydrophilic Manipulation capability a. Torque force b. Torque response GAIA Next 3 ASAHI composite guide wire
- 63. Penetration efficacy a. Tipload (~ 10mm) ☛ 6.0gf up or down ? b. Tip flexibility (~ 30mm) up or down ? Others up or down ? GAIA Next 3
- 64. Stiff guide wire GaiaThird Gaia Next 3 Conquest pro Miracle 12 Conquest pro 12 Conquest 8-20 Stiff > 4g Role of stiff CTO guide wire
- 65. Relation of tipload and penetration force 73 0 100 200 300 400 500 600 700 800 900 1000 Gaia Next 3 Gaia 3rd Conquest Pro Miracle 12 Conquest Pro 8-20 Conqeust Pro 12 Penetration force [gf/mm2] 0 5 10 15 20 25 Gaia Next 3 Gaia 3rd Conquest Pro Miracle 12 Conquest Pro 8-20 Conqeust Pro 12 Tip load
- 66. 0.0 200.0 400.0 2 5 1015 20 25 30 Gaia Third Gaia next 3rd Conquest Pro Conquest Pro12 Conquest Pro8-20 Miracle 12 74 Stiff - Tip flexibility [mm] Guide wire [mN]
- 67. Next choice Tip flexibility☛ GAIA Next 2 > GAIA Next 3 More deflectable wire is required!
- 68. Target : LAD#6 CTO Case 3 GW : GAIA Next 2 MC : SASUKE
- 69. Target : LAD#6 CTO Case 3 GW : GAIA Next 2 MC : SASUKE
- 70. GAIA Next 2vs GAIA Next 3 79
- 71. Message to TakeHome Please understand the wire structure in detail which provide wire attributes and performance in each procedural situation.
- 72. 20th CTO Club June14-15, 2019, Nagoya, Japan www.cct.gr.jp/ctoclub