Choice And Use Of Appropriate Guidewire in PCI

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

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.

Lesion specific CTO approaches

SLIDING

 Micro-channels present
 ISR total occlusions
 STAR technique

Hydrophilic wires


SLIDING

• Pilot, Whisper
• Fielder wires

• Cordis – Shinobi

Hydrophilic wires


DRILLING
(controlled)

“Workhorse technique”
Most CTOs with discrete
entry point after initial attempt

with soft (intermediate wires)

Stiff , hydrophobic
non-tapered wires


DRILLING
(controlled)

• Miracle 3, 4.5, 6
• Cross It 100, 200, 300
• Medtronic Persuader 3,6 gm

Stiff , hydrophobic
non-tapered wires


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


Penetration

Asahi Conquest (regular) and Pro
Cross It 400
Persuader 9 gm

Super stiff
tapered wires

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

Pseudostenosis caused by wire in
tortuous vessel

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.

 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
 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
cm
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.

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.

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.

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.

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 COATING

CATEGORISATION

 TIP COATING(hydrophilic hydrophobic, No coating)

CATEGORISATION

 TIP STYLE

CATEGORISATION

 TIP STYLE(one-piece core-to-tip, two-piece core with

shaping ribbon),
 TIP TAPERING

CATEGORISATION


shaping ribbon),
 TIP TAPERING(tapered, untapered),
 CORE MATERIAL

CATEGORISATION


shaping ribbon),
 CORE MATERIAL(stainless steel, Nitinol, high-tensile
stainless steel),
 DEVICE SUPPORT

CATEGORISATION
shaping ribbon),
stainless steel),
 DEVICE SUPPORT(light, moderate support, extra

support),
 TARGET LESION

CATEGORISATION
shaping ribbon),
stainless steel),
 DEVICE SUPPORT(light, moderate support, extra
support),
 TARGET LESION(workhorse/frontline wires, CTO wires,
wires for tortuous lesions,

 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
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

CTO Wire properties

(1)Tip load
Floppy wires
<1g
CTO Wires
>3g

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.

SLIDING

 Micro-channels present
 ISR total occlusions
 STAR technique

Hydrophilic wires

SLIDING

• Pilot, Whisper
• Fielder wires

• Cordis – Shinobi

Hydrophilic wires

DRILLING
(controlled)

Most CTOs with discrete
entry point after initial attempt

with soft (intermediate wires)

Stiff , hydrophobic
non-tapered wires

DRILLING
(controlled)

• Miracle 3, 4.5, 6
• Cross It 100, 200, 300
• Medtronic Persuader 3,6 gm

Stiff , hydrophobic
non-tapered wires

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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