Introduction to Sports Injuries by- Dr. Anjali Rai
Choice And Use Of Appropriate Guidewire in PCI
1. CHOICE AND USE OF APPROPRIATE
GUIDEWIRE IN PCI
SAJY KURUTTUKULAM
2. CONTENTS
COMPONENTS OF A GUIDE WIRE
WORKHORSE WIRE
WIRES FOR DIFFERENT OCCASIONS
TRACKABILITY
KNOW YOUR WIRE
CLASSIFICATION
PROPERTIES OF AN IDEAL WIRE
3. COMPONENTS OF A WIRE
core,
distal tip and
outer covering.
4. 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.
6. 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.
13. The selection of a guidewire
essential component
INFLUENCED BY
vessel anatomy
the lesion morphology
the devices to be used
operator's experience and preference.
14. 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)
15. 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
16. 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.
17. 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..
18. 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)
34. 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.
43. 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
45. 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
46. Lesion specific CTO approaches
Penetration
Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm
Super stiff
tapered wires
59. 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.
60. 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.
61. 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.
83. 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
84. 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.
93. 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
95. 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
96. Lesion specific CTO approaches
Penetration
Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm
Super stiff
tapered wires
97.
98.
99.
100.
101.
102.
103.
104. 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.
105. 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.
106. 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.
107. 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
108. 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.
120. 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
121.
122. 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.
127. 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
128.
129. 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
130. 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.
131. 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.
132. 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.
133. 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.
134. 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.
135. 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
136. 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
137. 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.
141. 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.
142. 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.
144. Wire tip
Wire tip – important component.
Decides the wire characteristics
CTO Wires
145. 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
146. 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.
151. 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
152.
153.
154.
155. Side branch at CTO
1. Hydrophilic wires
may not succeed.
2.Careful penetration
to enter the plaque.
156. 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.
157.
158.
159. 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.
164. 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
165. 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
166. 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
167. 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
168. 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
169. 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,
173. 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.
174. Components of a guide wire
Core
Outer covering
Distal tip
175. The effect of different guide
wires on the trackability of
coronary stent
delivery systems
176. 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
177.
178. 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
187. 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
188. 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.
196. 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
198. 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
199. Lesion specific CTO approaches
Penetration
Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm
Super stiff
tapered wires