interventional cardiology, Guiding catheters, wires, and balloons equipment and results
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Guiding catheters, wires, and balloons equipment and results
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interventional cardiology, Guiding catheters, wires, and balloons equipment and results
- 1. Guiding Catheters, Wires, and Balloons: Equipment and Results
- 2. Disclosure • SB: Medtronic, BSc, Abbott Vascular,Gilead • Advisory Board: Medtronic, Abbott Vascular, Philips • All faculty disclosures are available on the CRF Events App and online at www.crf.org/tct
- 3. PTCA-Fracturing and Splitting Plaque
- 4. Design Characteristics of PTCA Balloons • Over the wire (OTW) • Rapid exchange (RX), Monorail • Perfusion • Fixed wire • Cutting balloon • Scoring balloon-Angiosculpt
- 5. Over the Wire (OTW) • Consists of a balloon catheter with a movable guidewire passing through the entire length of its lumen • OTW requires 2 operators • OTW provides better pushability • 300 cm steerable wire is typically used • Balloon catheter shafts are typically 145 to 155 cm long • 25% of the system use in the U.S. Product diagram courtesy of the manufacturer.
- 6. Over the Wire (OTW) Advantages • Ability to change wire without removing catheter • Superior pushability because entire catheter body runs over wire Disadvantages • Slightly larger profiles and shaft sizes • Typically needs 2 operators • Can take more time, requiring more fluoroscopy
- 7. Rapid Exchange (RX) • Guidewire exits balloon catheter several centimeters proximal to the distal tip • Guidewire travels separately from the balloon catheter • RX allows the operator to fix the wire with one hand & advance the balloon with the other • Single operator • 180 through 195 cm steerable guidewire is typically used • 75% of the system use in the U.S. and greater than 95% in the remainder of the world Product diagram courtesy of the manufacturer.
- 8. Rapid Exchange (RX) Advantages • Single operator • Allows for quick exchanges over a short guidewire Disadvantages • Can’t reshape or exchange wire without losing position • Guidewire difficult to place without support of balloon • Pushability may be compromised due to the short wire lumen
- 9. Balloon Overview Illustrations are artist’s rendition and are not drawn to scale. Working Length Proximal Taper Distal Taper Tip Length Tip Entry Crossing Profile
- 10. Balloon Dilatation Catheter Components 2. Tip 3. Markers 5. Catheter Platform 1. Balloon 4. Distal Shaft 6. Coating Illustrations are artist’s rendition and are not drawn to scale.
- 11. Characteristics
- 12. 5 Key Balloon Attributes • Entry – pushability and crossability • Tracking – guidewire compatibility • Crossability – profiles and transition angles • Dilatation – balloon material and shoulders • Withdrawal – rewrap
- 13. Definitions • Nominal - the pressure (in atm.) at which the balloon reaches its stated size • Rated Burst Pressure - (RBP) pressure at which 99.9% of all balloons will not burst at or below (with 95% confidence interval) • Working Range - range between nominal and rated burst pressure
- 14. Compliance • Compliant - Diameter increases in ratio with the increase in inflation force (size of balloon may grow beyond the ceiling of clinical safety) • Non-compliant - Reach and maintain specified size regardless of inflation pressure (little to no flexibility in vessel sizing) • Semi-compliant - Wide working pressure range with controlled flexibility in balloon sizing
- 15. 2.5 2.7 2.9 3.1 3.3 3.5 3.7 3.9 2 4 6 8 10 12 14 16 18 20 mm atmSemi-Compliant Non-Compliant Compliant Balloon Compliance
- 16. Multi- Function Very Durable Multi FunctionHighly Crossable Ultra-Tight Lesions Tortuous Anatomy Pre-Dil & Post Dil Heavy Calcification Balloon Differentiation Compliant Semi-Compliant
- 17. Marker Bands • Radiopaque bands are swaggered into the shaft of the balloon to determine balloon placement under fluoroscopy • Bands can be either dual markers or a single center marker Product diagram courtesy of the manufacturer.
- 18. Balloon Material POC PE Nylon PET More Compliant Less Compliant Manufacturers use different balloon materials and blends to design their balloon portfolio.
- 19. Balloon Angioplasty Results • Plain old balloon angioplasty (POBA )has a high rate of acute recoil and restenosis rates vary from 10-60% depending on size, diameter, complexity of the lesion and patient related factors. • The use of the cutting balloon/angioscore have reduced these rates and may be an option for complex procedures and small less important branch vessels when stenting is not desired or to prepare the lesion prior to stenting. • Currently, PTCA is used traditionally for pre-dilating prior to stenting and post-dilatiation to maximally expand a stent. • The era of the drug eluting balloon (DEB) is on the horizon and will change therapy depending on future randomized trials
- 20. Guide Catheters
- 21. Diagnostic Catheter Function • Vehicle for contrast injection • Pressure measurement • Angiographic assessment
- 22. Guiding Catheter Function • Conduit for device & wire transport • Support for equipment advancement • Vehicle for contrast injection • Pressure measurement • Angiographic assessment Source: Grossman’s Cardiac Catheterization, Angiography, and Intervention
- 23. Basic Catheter Construction • Materials • Layers • Catheter size Outer LayerMiddle LayerInner Layer
- 24. Catheter Size • Outer diameter = French size (5-10F) • Inner diameter = Inches (thousandths) • Length = Centimeters (cm) ID=0.000” OD=F Length=cm
- 25. Curve/Tip Length 3.0 4.0 5.0 Judkins Left P S P = Primary Curve S = Secondary Curve Tip Length = P to S distance (cm) Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
- 26. Curve Length 5.0 4.0 3.04 . 0 Lateral Wall Support 3.0 4.0 5.0 Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention 3.0 4.0 5.0 Tip Orientation
- 27. Backup Support Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
- 28. Other Key Features • Torque and tip control • Soft tip • Kink resistance • Variety of shapes • Adequate lumen sizes • Radiopacity Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
- 29. Access Approach • Femoral Extensive physician experience Easy catheter manipulation Bleeding at puncture site • Radial & Brachial Little physician experience More difficult catheter manipulation Infrequent bleeding at puncture site Other possible complications Source: The Manual of Interventional Cardiology
- 31. Source: The Manual of Interventional Cardiology Acute Superior Inferior Anterior Posterior Vessel Takeoff
- 32. Left Coronary Artery Catheter Selection • Judkins Left JL3 JL3.5 JL4, JL4ST (Short Tip) JL5 JL6 • Amplatz AL1, AL2, AL3 • Multi Purpose (MPA) Source: The Manual of Interventional Cardiology
- 33. Right Coronary Artery Catheter Selection • Judkins Right JR3 JR3.5 JR4, JR4ST (Short Tip) JR5 JR6 • Amplatz AR1, AR2 • Hockey Stick • Multi Purpose (MPA) Source: The Manual of Interventional Cardiology
- 34. Graft Cannulation Internal Mammary Artery Grafts Saphenous Vein Grafts
- 35. Guide Wires
- 36. Guide Wire Guide Wire Support Stiffness Malleabillity Torque Control
- 38. Core Material Advantages • Flexible • Durable Disadvantages • Store torque • Risk of fracture NITINOL Advantages • Support • Push • Torque Disadvantages • Kink • Less flexible STEEL
- 39. Wire Coating HYDROPHILLIC • attracts water • It is applied over polymer or stainless steel (including tip coils) • Thin, non-slippery solid when dry, needs lubrication to perform • Becomes gel when wet • Reduces friction • Increases trackability HYDROPHOBIC • repels water • Silicone on working area of wire, excluding tip • No actuation/wetting required • Reduces friction • Increases trackability
- 40. Guide Wire - Coating NO COATING HYDROPHOBIC HYDROPHILLIC POLYMER AND HYDROPHILLIC TACTILE FEEDBACK LUBRICITY
- 41. Guide Wire - Tip TIP LOAD SHAPE COAT JOINTS COILS DESIGN
- 42. Tip Design CORE-TO-TIP SHAPING RIBBON
- 43. Wire Selection Workhorse Wires • BMW • BMW Universal • Runthrough • Hi-Torque Floppy • Prowater Extra Support • ACS Intermediate • Choice ES • Stabilizer • Wiggle Wire CTO Wires • Stiff Miracle Confianza Persuader • Slippery Fielder FC,XT Pilot 50-200
- 44. Balloons, Guides, Wires • Core products for the Interventional cardiology community • Each product is critical to the ultimate success of the procedure • They are used in every case and in many cases several balloons and wires will be utilized • Enhancements to these products occur regularly and help advance the field
- 45. Guiding Catheters, Wires, and Balloons: Equipment and Results ABC’s of Interventional Cardiology TCT 2014 THANK YOU!