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!