Choice And Use Of Appropriate Guidewire in PCI

SAJY KURUTTUKULAM

CHOICE AND USE OF APPROPRIATE GUIDEWIRE IN PCI

CONTENTSCOMPONENTS OF A GUIDE WIREWORKHORSE WIREWIRES FOR DIFFERENT OCCASIONSTRACKABILITYKNOW YOUR WIRECLASSIFICATIONPROPERTIES OF AN IDEAL WIRE

COMPONENTS OF A WIREcore, 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 MATERIALSStainless steel Provides excellent support, pushability, torque, good shapability.

BUT Less flexible in comparison to newer core materials and more susceptible to kinking.

CORE-MATERIALSNITINOL Excellent flexibility, steering Kink resistant

Negative Less torqueability than SS

Table 14 Categorisation/classes of guidewires

Workhorse GuidewiresATW/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 guidewireessential component

INFLUENCED BYvessel anatomy the lesion morphology the devices to be used operator's experience and preference.

LEFT MAIN PCIThe 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 PCIThe 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 PCIIn 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.

DISSECTIONSChOICE 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 LESIONSChoICE 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)

Floppy

ES – Extra-Support

Grand-Slam

Iron-man

TORTUOUS ANATOMYvery floppy wire with support for

device delivery could be usedBMW FIELDER FCWHISPER ESWIGGLE WIRE

MAIN VESSEL TRACKING

Short tapering better

Tip load and support for Asahi Intecc guidewires

CTO Wires

Hydrophilic Non-coated / Hydrophobic

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

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

Hydrophilic wires

• Pilot, Whisper

• Fielder wires

• Cordis – Shinobi

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”

Stiff , hydrophobic non-tapered wires

• Miracle 3, 4.5, 6

• Cross It 100, 200, 300

• Medtronic Persuader 3,6 gm

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

Super stiff tapered wires

Asahi Conquest (regular) and Pro

Cross It 400

Persuader 9 gm

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

Figure 10 Components of a guidewire

HOW TO CLASSIFY CORONARY GUIDE WIRES?

CLASSIFICATIONNO UNIFORM CLASSIFICATION BUT SOME CATEGORISATION

Table 14 Categorisation/classes of guidewires

Figure 10 Components of a guidewire

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.

Table 14 Categorisation/classes of guidewires

SPECIFIC PURPOSE WIRESPRESSURE WIREMARKER WIREROTABLATOR WIREWIGGLE WIRE

“Support”Indicator of the core strength

More stronger the core – more support

Floppy

ES – Extra-Support

Grand-Slam

Iron-man

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)

Hydrophilic Non-coated / Hydrophobic

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

STAR technique

Hydrophilic wires

Lesion specific CTO approaches

SLIDING

Hydrophilic wires

• Pilot, Whisper

• Fielder wires

• Cordis – Shinobi

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”

Stiff , hydrophobic non-tapered wires

• Miracle 3, 4.5, 6

• Cross It 100, 200, 300

• Medtronic Persuader 3,6 gm

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

Super stiff tapered wires

Asahi Conquest (regular) and Pro

Cross It 400

Persuader 9 gm

Figure 13 Relationship between coating, polymer cover, lubricity and tactile feedback

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 SoftTip load: 1.0 g

Radiopaque length: 3 cmOutside diameter: 0.014"Coating: HydrophobicTip style: Core to tipPolymer 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

CLASSIFICATIONPROPERTIES OF AN IDEAL WIRECOMPONENTS OF A GUIDE WIREWORKHORSE WIREWIRES FOR SPECIAL OCCASIONSTRACKABILITY

The effect of different guide wires on the trackability of coronary stentdelivery systems

The effect of different guide wires on the trackability of coronary stentdelivery 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 BALANCETip load: 0.6 g

Radiopaque length: 3 or 40 cmOutside diameter: 0.014"Tip Outside diameter: 0.014"Coating: Hydrophilic or -phobicTip style: Shaping RibbonPolymer cover: noneCore 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

CoatingThe 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)

PROSOffer good manoeuvrability in tortuous vessels.

CONSMore likely to penetrate beneath plaque and dissectHydrophilic wires also tend to select small branches

or vasavasorum and perforate more frequently.

Non-Coated / Hydrophobic wires ProsMore controllable (and therefore less likely to dissect)Provide better tactile feel

ConsPoor trackabilityWire 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 SoftTip load: 1.0 g

Radiopaque length: 3 cmOutside diameter: 0.014"Coating: HydrophobicTip style: Core to tipPolymer cover: none

Workhorse GuidewiresATW/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.

Harikrishnan.S SCTIMST

www.sctimst.ac.in

Guidewires for PCI

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.

1982John B Simpson et al reported the first experience with a new over-the-wire 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

Tip Radiopacity: 2cm; two 5mm marker system

BOSTONForté® Floppy Marker Wire

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 youThank 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 stentdelivery systems

The effect of different guide wires on the trackability of coronary stentdelivery systems

friction properties and flexibility of the stent system

constitution of the vessel properties of the guide wire

HI-TORQUE BALANCE Tip load: 0.6 g

Radiopaque length: 3 or 40 cmOutside diameter: 0.014"Tip Outside diameter: 0.014"Coating: Hydrophilic or -phobicTip style: Shaping RibbonPolymer cover: noneCore Material: ELASTINITE Nitinol

TIP DESIGNCORE 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)

Hydrophilic Non-coated / Hydrophobic

TIP TIP

Non-tapered Tapered Non-tapered Tapered

Miracle 3,4.5,6 Cross It 100 - 400

Pilot 50,100,150 Conquest Pro

Tapered wiresPros:Minimizes tip resistance and Select small vascular micro-channels within the

CTO.

ConsThese 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

Hydrophilic wires

• Pilot, Whisper

• Fielder wires

• Cordis – Shinobi

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”

Stiff , hydrophobic non-tapered wires

• Miracle 3, 4.5, 6

• Cross It 100, 200, 300

• Medtronic Persuader 3,6 gm

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

Super stiff tapered wires

Asahi Conquest (regular) and Pro

Cross It 400

Persuader 9 gm

(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

REFERNCESJACC INTERVENTIONS APRIL2012PCR-EAPCI TEXT BOOK