Basic Wire Skills
and Selection
Martin B. Leon, MD
Columbia University Medical Center
Cardiovascular Research Foundation
New York City
Complex PCI: Left Main and CTO Summit
February 24, 2012; New York City
Disclosure Statement of Financial Interest
Martin B. Leon, MD
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Grant/Research Support
Company
Abbott, Boston Scientific, Medtronic
Guide Wire Clinical Segmentation
Workhorse/
Frontline
Tortuous
Anatomy
Extra
Support
CTO
Lesions
Guide Wire Clinical Segmentation
Workhorse/
Frontline
Tortuous
Anatomy
Extra
Support
CTO
Lesions
During the course of CTO therapy, a variety of
diverse guidewires are needed to manage both
CTO crossing and subsequent lesion treatment
Guidewire Anatomy for Dummies
Coils & covers
Tip styles
Core tapers
& materials
Coatings
Core diameter
Guidewire Anatomy for Dummies
Tip styles
Core-to-tip tactile feedback and control
Shaping ribbon shape retention and softness
Special shapes tapered, flat, etc.
Guidewire Anatomy for Dummies
Coils & covers
Coils provide tactile feedback, radiopacity, and maintain
constant diameters
Polymer covers (sleeves or jackets) reduce friction and
improve trackability
Guidewire Anatomy for Dummies
Core tapers - longer = improved tracking and decreased
prolapse; shorter = increased support and torque response;
transitionless = progressive support and maximal tracking
Core tapers Core materials stainless
& materials steel (increased push) vs.
nitinol (increased flexibility)
Guidewire Anatomy for Dummies
Core diameter - larger = increased support;
smaller = enhanced tracking and flexibility
Core diameter
Guidewire Anatomy for Dummies
Coatings
Coatings are designed to reduce surface friction, improve
device interactions, and improve tracking or tactile response
Two types - hydrophilic (slippery gel-like) for tracking and
hydrophobic (wax-like, e.g. silicone) for tactile response
Hallmarks of a CTO Guidewire
Tip styles - core-to-tip designs; sometimes tapered
Coils and covers - some favor increased radiopacity;
jointless coils for improved torque response; polymer
covers for selected applications (e.g. ISR, calcified
lesions, micro-channels)
Core tapers and materials - shorter tapers for improved
torque response; generally stainless steel
Core diameters - larger for increased support and
torque response
Coatings - hydrophilic for tracking (body) and
hydrophobic for torque response (esp. near tip)
Tip Stiffness Test Equipment
Effect of Microcatheters on
Guidewire Stiffness
T ip Stiffne ss ac cord ing to the Leng th Extend ing from the T ip of a
Mic roc athete r
60
50
40
Mirac le 12
30
gfs
Mirac le 6
20
Mirac le 3
10
0
5mm
7mm
9mm
11mm
13mm
15mm
17mm
19mm
CTO - Milieu Considerations
Planned procedure not ad hoc
Careful assessment of symptoms, and target site
viability + ischemia (righteous indication)
Proper diagnostic angiograms
Must visualize collaterals and distal parent vessel
beyond the CTO segment (consider bilateral
angiography during diagnostic procedure)
Strong guiding catheter support
7-8 Fr, trans-femoral preferred for antegrade
Sideholes for RCA and small ostial LM
Bilateral angiography from the outset in
essentially ALL cases
Obsessive management of radiation exposure
and contrast volume
CTO - Milieu Considerations
Heparin anticoagulation
No bivalirudin and keep ACTs 200-250 secs
Patient comfort
Adequate sedation and foley catheter
Other factors
Access issues (consider long sheaths)
Status of pericardium (post-CABG issues)
ZEN philosophy
Spiritual adventure you cannot be beaten
by the vessel persistence reigns supreme
(consider 2nd attempts)
Patience, patience, patience
Experience, experience, experience
CTO Success: 1st and 2nd Attempts
CTO Success: 283 CTOs (72%) 272pts
Successful
41CTOs(70%)
Successful
242 CTOs(61%)
1st Attempt
395 CTOs
379 pts
2nd Attempt
59CTOs(39%)
Unsuccessful
153 CTOs(39%)
CUMC CTO experience
No Further
Attempt
94CTOs(61%)
Unsuccessful
18CTOs(30%)
CTO Failure: 112 CTOs (28%)
107pts
CTO Lesion Assessment
Proximal and distal caps
Calcification (esp. at entry point)
Angulation proximal vessel and throughout
CTO segment
CTO segment length
Collateral pattern and anatomy
Sidebranch relationships (esp. at proximal and
distal caps)
Distal vessel anatomy and disease
Donor and CTO vessel anatomy for catheter and
guidewire selection
Is There a Time NOT to Try ?
Maybe
Long Tortuous CTO Segment Gap
Severe Calcification
Poor Distal Vessel Visualization
Esp. when, no prospect for retrograde
recanalization
CTO Guidewires Tip Shaping
Primary bend ~ 60
1-2mm from tip
Secondary
bend ~ 10-15
Antegrade CTO Wiring Techniques
lumen
proximal cap
CTO
distal cap
Uncontrolled drilling
FAILURE!
lumen
Antegrade CTO Wiring Techniques
lumen
proximal cap
CTO
Controlled Drilling
(90 degree arc)
distal cap
lumen
Guidewire Operator Techniques
DRILLING
(controlled)
Short tip curve (~ 2mm) at 30o; sometimes a
proximal secondary curve at 10-15o
Controlled rotational 90o arc tip motion with
gentle forward probing
Start with moderate stiffness tips and stepwise
increases in tip stiffness
Premium on tactile responses
CTO Guidewire Categories
DRILLING
(controlled)
Abbott PROGRESS - 120, 140T, and
200T
Asahi MIRACLE Bros - 3-12 gm
Medtronic PROVIA - 3, 6, and 9 gm
Lesion-Specific CTO Approaches
DRILLING
(controlled)
Most CTOs with discrete entry point;
after initial attempt with soft or
hydrophilic wires
Workhorse technique
Parallel wiring technique
Antegrade CTO Wiring Techniques
lumen
proximal cap
CTO
distal cap
Penetration Technique
lumen
Guidewire Operator Techniques
PENETRATION
Similar tip shape and curves as drilling technique
Precise movements of the guidewire tip
Minimal rotational tip motion with more
aggressive directed forward probing
Tip stiffness (+ taper) should penetrate even
heavily calcified entry cap (9-12 gms)
Reduced tactile responsiveness
CTO Guidewire Categories
PENETRATION
Abbott PROGRESS - 140T, 200T
Asahi-Abbott CONFIENZA (regular
and PRO) - 9 and 12 gm
Medtronic PROVIA - 12, 15 gm
Lesion-Specific CTO Approaches
PENETRATION
Blunt entry point, short straight CTO
segments
Heavily calcified or resistant lesions
Alternative to drilling after initial soft wire
failure or after drilling wire failure
Parallel wiring technique
CTO Pathology
Homogenous hard plaque lower
success rates - intimal dissection likely
Antegrade CTO Wiring Techniques
lumen
microchannel
proximal cap
CTO
Sliding technique
distal cap
lumen
Guidewire Operator Techniques
SLIDING
Longer and shallower tip shapes and no
secondary bends
Simultaneous gentle tip rotation and probing
Almost no tactile response
Takes advantage of reduced guidewire surface
friction requires polymer cover/coating
CTO Guidewire Categories
SLIDING
Abbott PILOT and Whisper
BSC PT
Asahi Fielder - FC and XT
Abbott PROGRESS - 40, 80
ASAHI Fielder Guidewires
16cm Polymer Sleeve & SLIP COAT
16cm Radio-opaque spring coil
Stainless Steel Core
Fielder XT
0.009
0.014
PTFE Coating
11cm Spring Coil
Stainless Steel Core
3cm Radio-opaque Coil
Fielder FC
0.014
PTFE Coating
20cm Polymer Sleeve & SLIP COAT
12cm Spring Coil
3cm Radio-opaque Coil
Stainless Steel Core
0.014
PTFE Coating
22cm Polymer Sleeve & SLIP COAT
Fielder
Lesion-Specific CTO Approaches
SLIDING
Microchannels present or sub-total
occlusion (residual channel)
ISR total occlusions
Some calcified and angulated lesions
STAR technique (subintimal reentry)
CTO Pathology
Micro-channels increase success
Hydrophilic wires and low profile tips
facilitate crossing
HI-TORQUE PROGRESS Guidewires
30.0 cm
3 cm coil
5 mm
Uncoated tip
Hydrophilic coated + polymer sleeve
Variation in
tip diameter
& stiffness
Uncoated,
exposed tip
coils
Tapered
hydrophilic
polymer
Core-to-tip
transitionless
core
Lubricious
proximal
coating
Step up
approach to
penetrate
lesions
Tactile
feedback,
minimize
perforation
Lesion
crossing and
distal access
Torque and
control
device
compatibility
HI-TORQUE PROGRESS Guidewires
Penetration Power
Tip Diameter 0.009 0.012
Area of GW Tip
r
(Guide Wire Tip)
Tip Stiffness / Area of GW Tip (Area =
.004kg/ (3.14*.0062)
PROGRESS 40
HI-TORQUE PROGRESS Guidewires
200
HT PROGRESS 200T (13.3g, .009 tip)
150
HT PROGRESS 140T (12.5g, .0105 tip)
HT PROGRESS 120 (13.9g, .012 tip)
100
HT PROGRESS 80 (9.7g, .012 tip)
50
HT PROGRESS 40 (4.8g, .012 tip)
Penetration Power
HI-TORQUE PROGRESS Guidewires
SLIDING TECHNIQUE:
DRILLING TECHNIQUE :
Functional occlusions or very
narrow lesions; lubricious polymer
sleeve
Advanced using gentle
movements; tactile feedback and
steerability; step up with stiffer
guide wires
PROGRESS 40 (4.8g, .012 tip)
PROGRESS 80 (8.9g, .012 tip)
PROGRESS 120 (13.9g, .012 tip)
PROGRESS 140T (12.5g, .0105 tip)
PROGRESS 200T (13.3g, .009 tip)
PENETRATING TECHNIQUE:
Penetrating and aiming at target; precisely
controlling guidewire direction; tapered tip
for high penetrating forces
PROGRESS 140T (12.5g, .0105 tip)
PROGRESS 200T (13.3g, .009 tip)
Corsair Micro-catheter
For crossing & dilating small vessels: SHINKA Shaft
Tungsten braids for
visibility
0.12 mm x 2pcs
0.07 mm x8pcs
8 thin wires wound with 2 larger ones = pusahbility, trackability and support.
5 mm; loaded with
tungsten powder
0.8 mm; Platinum marker coil
Corsair Micro-catheter
Also for antegrade crossing as support catheter
Rotation Resistance Reduction
SHINKA-Shafts spiral structure transmits rotation to the
distal tip. This rotation gives CORSAIR its crossing
performance through tortuous channels.
ASAHI SION Guide Wire
Core Wire
Twist Wire
Coil
ASAHI SION Guide Wire Design includes:
1. Composite Core Technology
2. Stainless steel high tension core
3. Jointless spring coils
4. SLIPCOAT hydrophilic coating over entire working
length
5. 3 cm radiopaque coils
Ropecoil
Antegrade CTO Wiring
Parallel wire technique
Wire 1 subadventitial space
Wire 2 redirected to true lumen path
First wire serves as marker, obstructs entry to false channel
2nd (parallel) wire (with greater tip stiffness) redirected to true lumen
based on subtle inflection from where wire 1 went offline
based on visual/tactile feedback
histopathology courtesy R Schwartz
Antegrade CTO Wiring
Parallel wire technique
First wire
Second wire
Antegrade CTO Wiring
See-Saw wire technique
Requires two micro-catheters; may use similar stiffness wires
Alternating wires repetitively redirecting into true lumen
most often used in tortuous long segment CTOs
based on visual/tactile feedback
histopathology courtesy R Schwartz
Guidewire Re-entry from
Subintimal Space
Small false lumen
True lumen
Large false lumen
Easy to make re-entry
Difficult to make re-entry
CTO Guidewires Tip Shaping
For penetrating the
entry point
For reentering to the
true lumen from the
subintima
Antegrade CTO Wiring Techniques
Severe Tortuosity
lumen
Miracle 3
distal cap
Miracle 6, 12
lumen proximal cap CTO
Parallel/See-saw wiring
with support catheters
Inner curve less apt to dissect
Antegrade CTO Wiring Techniques
IVUS guidance
Blunt occlusion at
sidebranch takeoff
IVUS in SB
Penetration
wire/technique
Confianza
IVUS
probe
lumen proximal cap
CTO
distal
cap
lumen
Alternatively, PTCA balloon in SB to help
direct wire into proximal cap ---open sesame
IVUS Guided Technique
for Finding the CTO Entry Point
CTO
*
Complex CTO
of MLCX
Where is the origin?
IVUS in
LA branch
CTO Wire Escalation Techniques
Drilling Strategy
Penetrating Strategy
Intermediate GW
Intermediate GW
Not cross
Stiffer GW (0.014 inch)
Not cross
Not cross
Other stiffer GWs
Not cross
Stiff Tapered GW
Stiff Tapered +/Hydrophilic
coating
CTO Wire Escalation Techniques
Hybrid Drilling-Penetration Strategy
Intermediate GW
Not cross
Stiff GW (0.014 inch MB 3 gm)
Not cross
Stiff tapered + hydrophilic coating
(Confienza pro 9, 12 gm)
CTO Wire Escalation Techniques
Hybrid Sliding-Drilling-Penetration
Hydrophilic GW (Fielder FC or XT)
Not cross
Stiff GW (0.014 inch MB 3 gm)
Not cross
Stiff tapered + hydrophilic coating
(Confienza pro 9, 12 gm)
Four CTO Summits (20042007)
Failure Modes (N=11)
Contributing factors
CTO - Procedural Considerations
When You Cant Cross (wire)
Advanced wiring techniques
Escalate, penetrate, parallel, see-saw
Advanced support techniques
Guiding catheters, micro-catheters (Finecross),
anchor balloon, mother-in-child, Tornus
IVUS guidance
Retrograde technique
Evaluate feasibility during planning stages
Crossover sooner than later
CTO - Procedural Considerations
When You Cant Cross (balloon)
Advanced PCI techniques
Buddy wire, lowest profile balloons, etc.
Advanced support techniques
Guiding catheters, anchor balloons
Crossing devices
Tornus or channel dilator (Corsair)
Excimer laser
Rotational atherectomy
Retrograde technique
CTO - Procedural Considerations
When to STOP!
Wire or device perforation with pericardial
effusion
Hemodynamic instability
Collateral vessel compromise
Extensive dissection compromising distal runoff
Contrast threshold
Radiation threshold
CSP = CTO Saturation Point futility threshold
Stage for second attempt
Refer to more experienced operator
CTO - Procedural Considerations
Recent TRENDS
Increased use of early hydrophilic wires (Fielder)
Rapid wire escalation (hybrid strategies)
Anchor balloon techniques for support
Use of Tornus and channel dilator
IVUS assisted situations
Early and more frequent initial retrograde
approach
CTA assistance (and co-registration future)
DES DES DES under most circumstances
2nd atempts are now comonplace
Progress with CTOs over the years
For the past 5-10 years, guided by our
Japanese colleagues, the art of CTO therapy
has become more generalized, now with
dedicated equipment and increasing success!
