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Choice and Use of Appropriate Guidewire in Pci: Sajy Kuruttukulam
Choice and Use of Appropriate Guidewire in Pci: Sajy Kuruttukulam
Choice and Use of Appropriate Guidewire in Pci: Sajy Kuruttukulam
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
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)
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 Hydrophilic
TIP TIP
Non-tapered Tapered Non-tapered Tapered
Miracle 3,4.5,6 Cross It 100 - 400 Pilot 50,100,150 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
SLIDING
Micro-channels present
ISR total occlusions Hydrophilic wires
STAR technique
Lesion specific CTO approaches
SLIDING
• Pilot, Whisper
• Fielder wires Hydrophilic wires
• Cordis – Shinobi
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
Stiff , hydrophobic
entry point after initial attempt non-tapered wires
with soft (intermediate wires)
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Penetration
Penetration
Grand-Slam
ES – Extra-Support
Floppy
Wire
– Light
types - Support
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
Hydrophilic
TIP TIP
Non-tapered Tapered Non-tapered Tapered
Miracle 3,4.5,6 Cross It 100 - 400 Pilot 50,100,150 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 Hydrophilic wires
STAR technique
Lesion specific CTO approaches
SLIDING
• Pilot, Whisper
• Fielder wires Hydrophilic wires
• Cordis – Shinobi
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
Stiff , hydrophobic
entry point after initial attempt non-tapered wires
with soft (intermediate wires)
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Penetration
Penetration
“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 "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.
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
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-the-
wire balloon system.
CTO Wires
Radio-opaque tip
Tip – coated/non-coated
Dual Core
Tortuous wires
Wiggle wire
BOSTON
Forté® Floppy Marker Wire
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
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
delivery systems
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
Hydrophilic
TIP TIP
Non-tapered Tapered Non-tapered Tapered
Miracle 3,4.5,6 Cross It 100 - 400 Pilot 50,100,150 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 Hydrophilic wires
STAR technique
Lesion specific CTO approaches
SLIDING
• Pilot, Whisper
• Fielder wires Hydrophilic wires
• Cordis – Shinobi
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
Stiff , hydrophobic
entry point after initial attempt non-tapered wires
with soft (intermediate wires)
Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Penetration
Penetration
Shaping ribbon
Any wire can perforate
Core characteristics
Core diameter
Larger diameters improve the support.
Core taper