Coronary guide wires

GUIDE WIRES IN CARDIOLOGY

1. CORONARY GUIDEWIRES,CHOICE AND APPROPRIATE USE IN PCI

2. GRUNTZIG First performed Angioplasty in 1974 1977 – First coronary angioplasty Polyvinyl Chloride balloon catheter with short guidewire attached to its tip

3. 1982 – Simpson reported First experience with over the wire balloon system It had an independently movable guidewire within the balloon dilation catheter

4. CONTENTS PURPOSE OF GUIDEWIRE COMPONENTS OF A GUIDE WIRE CLASSIFICATION WIRES FOR DIFFERENT OCCASIONS GUIDEWIRE MANIPULATION COMPLICATIONS

5. Purpose To track through the vessel To access the lesion To cross the lesion atraumatically To provide support for interventional devices

6. Guidewire main characteristics Torque control Is an ability to apply rotational force at a proximal end of a guidewire and have that force transmitted efficiently to achieve proper control at the distal end Trackability Is an ability of a wire to follow the wire tip around curves and bends without buckling or kinking, to navigate anatomy of vasculature Steerability Is an ability of a guidewire tip to be delivered to the desired position in a vessel Flexibility Is an ability to bend with direct pressure

7. Prolapse tendency Tendency of the body of a wire not to follow the tip around bends Radiopacity /visibility Is an ability to visualise a guidewire or guidewire tip under fluoroscopy. Tactile feedback Is tactile sensation on a proximal end of a guide wire that physician has that tells him what the distal end of the guidewire is doing Crossing Is an ability of a guidewire to cross lesion with little or no resistance Support Is an ability of a guidewire to support a passage of another device or system over it

8. STRUCTURE CORE-Material Diameter Core taper TIP COILS, COVERS & COATINGS

9. Core Inner part of the guidewire Extends through the shaft of the wire from the proximal to the distal part Stiffest part of the wire that gives stability and steerability

10. Core Material Core material affects the flexibility, support, steering and trackability Stainless steel superior torque characteristics, can deliver more push, provides good shapeability and excellent support more susceptible to kinking and is less flexible Nitinol pliable but supportive, less torquability than SS generally considered kink resistant & have a tendency to return to their original shape, making them potentially less susceptible to deformation during prolonged use

11. Core Diameter Influences the performance of the wire Larger diameter improves support and allows 1:1 torque response Smaller diameter enhances the flexibility Core taper Variable length Continuous/segmented Short taper and smaller number of wide spaces increases support and transmission of push force Longer tapers and larger numbers of segmented tapering increases flexibility

12. Tip Tapers distally to a variable extent 2-piece core- distal part of core does not reach distal tip of wire→ shaping ribbon, extends to distal tip 1-piece core- tapered core reaches distal tip. 2-piece→ easy shaping & durable shape memory 1-piece →better force transmission to tip & greater “tactile response” for operator

13. Coils, Covers & Coating Keeps the diameter at .014 inch Coils Stainless steel Outer coil Design – Coils placed over tapered core and tip of the wire Tip coil Design – Tip alone is covered with coils Flexibility, support, steering, tracking, visibility & tactile feedback Radio opaque platinum coils

14. Coils

15. 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. Many workhorse Wires – 3 cm distal radio-opaque tip

16. COVERS

17. Coating Distal half Affects lubricity and tracking Creates tactile feel Reduces friction Facilitates movement of wire within the vessel and deliverability of intervention equipment

18. 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.

19. HYDROPHOBIC 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.

20. Hydrophilic Applied over the entire working length of wire including tip coils Attracts water - needs lubrication Thin, non slippery, solid when dry→ becomes a gel when wet ↓friction ↑ trackability ↓ Thrombogenic ↓tactile feel- ↑risk of perforation Tendency to stick to angioplasty cath Useful in negotiating tortuous lesions and in “finding microchannels ” in total occlusions

21. Shapeability and shaping memory Shapeability - allows to modify its distal tip conformation Shaping memory - ability of tip to return back to its basal conformation after having been exposed to deformation & stress Both do not necessarily go in parallel SS core wires -easier to shape (↑memory- nitinol core) 2-piece core + shaping ribbon - easier to shape & ↑memory

22. HOW TO CLASSIFY CORONARY GUIDE WIRES?

23. CLASSIFICATION NO UNIFORM CLASSIFICATION BUT SOME CATEGORISATION

24. Table 14 Categorisation/classes of guidewires

25. Classification Based on Tip Flexibility Floppy – Eg :- Hi torque balance middle weight, Hi torque balance,Choice floppy Intermediate – Eg :- Hi torque intermediate, Choice intermediate Standard – Shinobi (Boston Scientific) Based on Device support Light – Eg :- Hi torque balance Moderate – Eg :- Hi torque balance middle Weight Extra support – Eg :- Hi torque whisper,Choice EXTRA

26. “Support” Indicator of the core strength More stronger the core – more support

27. Floppy ES – Extra-Support Grand-Slam Iron-man

28. Based on coating Hydrophilic : Eg :- CholCE TM PT Floppy Hydrophobic : Eg :- Asahi soft Depending on tip load Floppy, Balanced & Extra support Tip load - force needed to bend a wire when exerted on a straight guide wire tip, at 1 cm from the tip Floppy - <0.5g Balanced – 0.5-0.9g Extra support - >0.9g

29. BASED ON CLINICAL SCENARIO

30. Commonly Used 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

31. Balance Middleweight Universal wire (Abbott Vascular/Guidant, Santa Clara, CA) Quite steerable - tip is suitable for bending in a “J” configuration for distal advancement into the distal vessel bed with minimal trauma while still maintaining some torque shape retention relatively poor -any J configuration tends to become magnified over time → consequent loss in steerability moderately torquable - progression - minimal friction (light hydrophilic coating) - Dye injection may also be helpful to propagate distal advancement suitable for rapid, uncomplicated interventions low risk to cause dissections/distal perforations support - low to moderate

32. CHOICE FLOPPY

33. ALL TRACK WIRE(ATW) (CORDIS) General purpose, moderate support guidewire with floppy tip and integrated Flex-Joint ™ bond which contributes to flexibility and precise steering and atraumatic vessel tracking. The central core is coated with PTFE providing non- thrombogenic and durable platform for smooth delivery of multiple devices. The distal 3 cm radio-opaque tip is however, uncoated providing for good tactile response. For measurement of lesion length, four markers span 31 mm in 10 mm increments proximal to the radio-opaque tip. The only limitation of this wire is relatively poor tip support and lack of tip durability (multi-lesion/multi-vessel interventions may not be possible with a single wire)

34. ASAHI PROWATER FLEX Prowater ™ (Asahi Intec Co.) is the next generation Asahi wire which has a newly designed stainless steel core shaft and a hydrophilic coating over the spring coil (combination of stainless steel and platinum/iridium alloy) which offers higher support plus an improved torque performance as compared to previous generation Asahi soft guidewire . It is a highly maneuverable wire but at the same time it is very floppy. Thus it is possible to approach a variety of lesions including in tortuous lesions without causing any dissections, pseudo dissections and other complications with the wire.

35. SELECTION OF GUIDEWIRES FOR SPECIAL LESIONS

36. The selection of a guidewire Essential component INFLUENCED BY vessel anatomy the lesion morphology the devices to be used operator's experience and preference.

37. 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

38. 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.

39. These wires have higher risk to perforate the distal vessel if allowed to migrate into small side branches 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.

40. 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..

41. 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)

42. TORTUOUS ANATOMY V ery floppy wire with support for device delivery could be used BMW FIELDER FC WHISPER ES WIGGLE WIRE

43. CTO WIRES

44. CLASSIFICATION OF CTO WIRES

45. CTO guide wire techniques

46. Lesion specific CTO approaches SLIDING Micro-channels present CTO’s < 6 months ISR total occlusions STAR technique Hydrophilic wires Fielder,CrosswireNT , HT Pilot, Whisper, Choice PT

47. 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 MiracleBros (3 g, 4.5 g and 6 g), Persuader (3 g and 6 g) and Cross-IT XT (100/200/300)

48. 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 Conquest Pro (9 g, 12 g), Cross-IT XT 400, MiracleBros 12

49. GUIDEWIRES FOR RETROGRADE TECHNIQUES Fielder/ FielderFC    X - treme    Whisper    ChoICE PT2   Runthrough / Runthrough Hypercoat

50. COMMONLY USED CTO WIRES

51. Fielder™ / Fielder FC™ (Asahi Intec Co.) Special guidewire - distal coil coated with polymer sleeve & further coated with a hydrophilic coating Provides advanced slip performance & trackability for highly stenosed lesion & tortuous vessels Very good torque performance Combines both slide and torque performance Primary wire used in the retrograde technique of recanalization of CTO

52. Whisper Durasteel ™ Core-to-tip designed to improve steering, durable shape retention and tactile feedback Full Polymer cover with Hydrophilic coating intended for deliverability and smooth lesion access Responsease ™ “ transitionless ” core grind designed to provide improved tracking and better torque response Tip coils designed to provide softer, shapeable tip and also improve tactile feedback

53. CONQUEST SERIES

54. SUMMARY OF WIRES

55. Guidewire Manipulations Two step process Shaping the wire tip It minimizes the amount of force applied to the wire For steering into the vessel For visualization of torquing effort

56. Shaping the Wire Tip

57. Steering of the wire Small alternating rotations to left and right Excessive rotations should be avoided to prevent wire tip fracture

58. Optimum guide wire positioning Should be placed as distally as possible in the target vessel Allows extra support when crossing with balloon/stent catheters ↓ chance of the wire becoming displaced backwards across the lesion and necessitating re-crossing Avoid vessel perforation when positioning wires with hydrophilic coatings very distally

59. Strategies if Guidewire fails to cross Make the guide more coaxial with the lumen of the artery Use a balloon to direct the wire Modify the bend at the tip of the wire Change the wire

60. Complications Vessel perforations Uncommon <1% Risk factors Hydrophilic wires, core to tip Chronic total occlusions Diagnosis Angiographic diagnosis Small extraluminal extravasation of blush in the distribution of target vessel Emergency echo to r/o pericardial effusion and tamponade Prognosis Extent of extravasation into pericardium

61. Classification Type I – Extraluminal crater without extravasation Type II – Containing pericardial or myocardial blushing Type III - having≥ 1 mm diameter with contrast streaming and cavity spilling Management Reversal of anticoagulations Prolonged balloon inflation PTFE covered stent Coil embolization Use of gel foams

62. Pseudolesions /Concertina effect Stenosis that appears in any artery after the coronary guidewire is placed in the artery Appears in tortuous vessels that have been straightened out by the guidewire

63. Diagnosis Will disappear if the wire is withdrawn Replacement of a stiff wire with a flexible floppy wire eliminates pseudolesion Complications In some cases cause hemodynamic compromise and ischemia

64. Guidewire Entrapment Factors Presence of calcified vessels. Repeated use of wire for multiple interventions Repeated attempts at crossing the same lesion multiple times with the same wire Two wires may become entrapped when the “Buddy wire” technique is used Crossing stent struts

65. Management Advance a small profile balloon or a small caliber catheter (transit catheter) to the attachment site and pull back gently When a second or “buddy wire” gets trapped between a stent and the vessel wall gentle traction can be used Surgery

66. Guidewire fracture and Embolization Risk factors are calcified lesion, bifurcation stenting and prolonged procedures Management Surgery Snaring the Embolized wire fragment The Amplatz Gooseneck Microsnare The EnSnare Triple Loop Device The X Pro Micro Elite Snare The Alligator Retrieval Device Push and paste

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