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Choice And Use Of Appropriate Guidewire in PCI

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Information about Choice And Use Of Appropriate Guidewire in PCI
Health & Medicine

Published on January 8, 2014

Author: drheartin

Source: slideshare.net

Description

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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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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