1、Introduction wire techniques of chronic total occlusions,Jun Dai , M.D. Coronary disease center Fuwai Hospital CAMS & PUMC Beijing,Contents,Definition Pathology Angiography imaging PCI technical challengeguidewire technologyinterventional devicesrevascularization technology,Definition of CTO,Chronic
2、 total occlusions are defined as occlusions greater than 3(1) month old with angiographic TIMI 0 or TIMI 1 flow,The Spectrum of Lumen Morphology in CTO: Clinical Challenges,Necrotic core,Proteoglycan-rich,Calcification,Large recanalization channels,Inflammation,Small recanalization channels,Fibrotic
3、 plq: Negative remodelling,Chronic Total Occlusions,Whats Blocking up the Lumen?1. Dense Fibrotic Tissue: COLLAGEN!2. Calcification,Intraluminal Collagen,Extracellular Matrix: Collagen, Calcium,Increased fibrocalcific plaques with ageSrivatsa et al, J Am Coll Cardiol 1997:29:955-63,Intraluminal Calc
4、ification,Variables related success,Age of Occlusion Entry Length Tortuousity Calcium Collaterals Distal Vessel Size In-stent occlusion devices,Anatomic Descriptors of Procedural Success,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithm
5、s,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Hallmarks of a CTO Guidewire,Tip styles - core-to-tip designs; sometimes taperedCoils and c
6、overs - some favor increased radiopacity; jointless coils for improved torque response; polymer covers for selected applications Core tapers and materials - shorter tapers for improved torque response; generally stainless steelCore diameters - larger for increased support and torque responseCoatings
7、 - hydrophilic for tracking (body) and hydrophobic for torque response (body and tip),ASAHI MIRACLEBROS Family Straight Tip Guide Wires,Characteristics: Core-to-tip design (unique wire drawing process) Non-tapered tip 11 cm of radiopacity Smooth tractability & delivery with Joint-less distal coil te
8、chnology Hydrophobic coating Increasing tip loads 3 -12 gm Excellent tip shape ability & shape retention,ASAHI CONFIANZA 9 Tapered Tip Guide Wires,Characteristics: Very stiff tip 9 gm tip load Tapered tip - .009“ (for enhanced penetration) 20 cm radiopacitiy - Joint-less technology Hydrophobic coati
9、ng,Hydrophilic Coating,0.014”,Radiopaque Spring Coil,0.008”,PTFE,ASAHI CONFIANZA Pro “8-20” Tapered Tip Guide Wire,Characteristics: Stiffest tip - 20 gm Tapered tip - .008“ 20 cm radiopacitiy Joint-less technology Hybrid coating,Greatest penetrating force,The combination of a polymer cover and hydro
10、philic coating provides outstanding lubricity.,Tip coils beneath the polymer help facilitate tip shaping.,HI-TORQUE PILOTTM Family of Guide wire,Cordis SHINOBI & SHINOBI Plus CTO Guidewires,Unique flattened tip designed to cross subtotal occlusions,Flattened radiopaque coils,.0070” Corewire Support,
11、SHINOBI,.0100” Corewire Support,SHINOBI Plus,1. Coronary CTOs have many types of lesion morphologies.,Therefore, we have to use different types of wires for different lesion morphologies.,2. During a single CTO-PCI procedure, we often encounter different kinds of situations.,Therefore, we have to us
12、e a different type of wire for each situation.,Wire selection and wire handling,Guide Wire Selection,Most important considerations Torque response Tip feel (tactile response) Tip shape curve formation,Hydrophobic vs Hydrophilic Wires,Hydrophobic wires Provide better tactile response to operator Prov
13、ide operator improved tactile response to better navigate micro-channels To get into the “dimple” and use tip load to purchase fibrous capHydrophilic wires Hydrophilic wires with tapered tip may improve the locating of micro-channels, however micro-channels can lead to false lumens/sub-intimal space
14、s Hydrophilic wires tend to follow the path of least resistance and generally offer less tip control,Simplifyed sequence of wires,Easy case ( big vessel, straight )Crossit 100 Confianza pro,Difficult case (calcifyed, tortuous, smaller) Miracle 3g Prox. Tortuosity: lubricious wires Miracle 4.5-12 g C
15、onfianza wires,Parallel wire: Confianza 6g 12g,Why so difficult to cross it ?,Sub-Intimal Path,Wire technique for locating another channel Tip Shape Is Key,Wire tip for CTO,CTO,Stenosis,Tip 1 mm,Tip 2-3mm,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guide
16、wire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Guidewire Operator Techniques,DRILLING (controlled),Guidewire Operator Techniques,Short tip curve ( 2mm) at 45-60o; sometimes a proximal secondary curve at 15-30o Controlled rotational tip motion with gentle forward probing Start with
17、 moderate stiffness tips and stepwise increases in tip stiffness Premium on tactile responses,PENETRATION,Guidewire Operator Techniques,Similar tip shape and curves as drilling technique Precise movements of the guidewire tip Minimal rotational tip motion with more aggressive directed forward probin
18、g Tip stiffness should penetrate even heavily calcified entry cap (9-12 gms and tapered) Reduced tactile responsiveness,Allways steer towards inner curve ! Twist gently , push and pull ! Dont inject dye via OTW-catheter !,In curved vessels, the optimal site for penetrating the fibrous cap is towards
19、 the myocardium (mural ),No !,Penetration vs. Controlled Drilling Drilling,Techniques of CTO Guidewire Manipulation,Techniques of CTO Guidewire Manipulation,Penetration vs. Controlled Drilling,Directional control of the tip is more precise in “Penetration”,Advancement of the tip is easier in “Contro
20、lled Drilling”,SLIDING,Guidewire Operator Techniques,Longer and shallower tip shapes and no secondary bends Simultaneous tip rotation and probing Almost no tactile response Takes advantage of reduced guidewire surface friction requires polymer cover,Anatomy of a CTO Guidewire,Guidewire Operator Tech
21、niques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,DRILLING (controlled),CTO Guidewire Categories,Abbott CROSS-IT wires (100, 200, and 300) Asahi-Abbott MIRACLE Bros wires Medtronic PERSUADER wires (3 and 6 gm),PENETRATION,CTO Guidewire Cat
22、egories,Abbott CROSS-IT 400 wire Asahi-Abbott CONFIENZA wires (regular and PRO) - 9 and 12 gm Medtronic PERSUADER wire - 9 gm,SLIDING,CTO Guidewire Categories,Abbott PILOT and Whisper wires BSC PT wires Cordis SHINOBI wires Asahi Fielder wires,Anatomy of a CTO Guidewire,Guidewire Operator Techniques
23、,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,DRILLING (controlled),Lesion-Specific CTO Approaches,Most CTOs with discrete entry point; after initial attempt with soft (intermediate) wires “Workhorse” technique,PENETRATION,Lesion-Specific CT
24、O Approaches,Blunt entry point Heavily calcified or resistant lesions Alternative to “drilling” as workhorse technique after initial soft wire failure,SLIDING,Lesion-Specific CTO Approaches,Microchannels present or sub-total occlusion (residual channel) ISR total occlusions Some calcified and angula
25、ted lesions STAR technique (subintimal reentry),Recent Guidewire Techniques,parallel wire techniques and extra support backup catheters Sesame open,Concept of Parallel Wire Technique,Tortuousity - Lesion on Bend,Seesaw: modifyed parallel wire technique,8 F guide 2 OTW balloons /catheters 2 wires sli
26、de parallel and are advanced in an alternating manner,Seesaw Wiring Parallel Wire Method with Double Support Catheters,marker,Seesaw Wiring,guide wires can exchangetheir roles as marker or penetrator,marker,CTO at branch: Sesame open (Saito),And entry can still not be found: Sidebranch technique (Ka
27、toh),Side Branch Technique,Anchoring technique using OTW balloon,Subintimal Tracking and Reentry (STAR) technique,Supportive 8Fr guide Create or use existing dissection in proximal CTO (Miracle, Confianza, etc.) 1.5mm balloon into track Whisper/Pilot 50 with tight “J” tip/”umbrella tip” Advance with
28、 balloon support, avoid spinning wire if possible May need pilot 150, 200 for proximal Use softest wire possible for distal (whisper) Reentry,Anterograde Dissection and Reentry,Subintimal Tracking and Reentry (STAR) Tips,Stiffer polymer wire (“J”) proximally if needed but always softer distally “J-b
29、end” media-to-media diameter Runoff vessels are key Visualization of target/runoff vessels is key Reentry strategy Dont lose true lumen distal branch, multiple wires if necessary PTCA pre-stent conservative size, pressures 12 ATM Bifurcation stenting only if absolutely necessary SB dissections may b
30、e OK DES Consider angiographic followup,Subintimal Tracking and Reentry (STAR) Patient Selection,Failure with conventional wire strategies (parallel, see-saw) No retrograde opportunity Relatively healthy distal vessel beyond CTO Minimal important branches in shear/dissection zone (RCA, OM) Strong cl
31、inical indication This is final measure, not first measure,Interventional techniques Improvement about CTO,Miracale 1995 Conquest 1999 Parallel and seesaw 2000 IVUS guide 2001 STAR 2003 SHOOTING and Fielder 2005 Tornus 2005 CART 2005,Retrograde approach,Anterograde failure Best septal collateral 7F
32、shorter guide catheter 70-90cm ACT300 seconds Microcathtersofter and hydrophilic wire,CTO Guide Wire Considerations(1),Start with softer guide wires Consider hydrophilic for sub-total occlusions Consider hydrophilic for heavy calcium Otherwise, start with soft, hydrophobic wires Advance to stiffer w
33、ires carefully Consider parallel wire techniques if subintimal Hydrophobic wires offer best tactile feel of lesion,Entry,Unfavorable,Favorable,Stump; no entry point; wire will favor side-branch,Well defined nipple into which wire can be directed, MIRACLEbros Family Confianza Family,Better torque per
34、formance,Less torque performance,Less penetration force,Better penetration force,Better crushing force,Less crushing force,Better tactile feeling,Less tactile feeling,Common CTO wire characters(2), MIRACLEbros Family Confianza Family,to advance in the hard CTO with tortuosity,to penetrate proximal o
35、r distal cap (parallel),to puncture from pseudo to true lumen (IVUS guide).,to puncture from pseudo to true lumen.,is more controllable,should be used,to penetrate proximal or distal cap,only when the near target is detected, Confianza Family should not be used,to seek the true channel or advance ov
36、er a long distance, particularly in CTO with tortuosity.,Common CTO wire characters(3),Support Catheters,1.5mm balloon Transit ILT support catheter Spectronetics Quick Cross St Judes Venture deflecting support catheter Tornus catheter,Facilitate wire exchange Improve torque response Provide extra ba
37、ckup to the Guidewire,Conquering Chronic Total Coronary Occlusions: newest technical approaches,Tornus Vibrating penetrating catheter guidewire systems Laser or radiofrequency ablation,Bottom line for CTO management,1. Before starting, weigh the odds by considering the features of high CTO success b
38、ased on angiography and available clinical information, especially the estimated age of the CTO. 2. Select appropriate initial guidewires, backup support guides and special support catheters for guidewire drilling. 3. Attempt standard wires before starting with hydrophilic guidewire. However, if pos
39、sible, limit creation of large false channels. 4. Use new technology sparingly at first, until experience grows. Concentrate skills in a small group of operators until success rates improve. 5. Learn the rules of engagement and know when to quit.,Procedural stopping points :,perforation device exit from the anticipated lumen evident futility of success after several hours of effort. fluoroscopic time exceeded 45 minutes, procedure time more than 2 hours contrast media loads in excess of 500 cc, it would be wise to stop, and if possible, try again on another day,
