慢性完全性闭塞的导丝技术介绍课件.ppt

Introduction wire techniques of chronic total occlusions,Jun Dai , M.D. Coronary disease center Fuwai Hospital CAMS & PUMC Beijing,Introduction wire techniques,Contents,DefinitionPathologyAngiography imagingPCI technical challenge guidewire technology interventional devices revascularization technology,ContentsDefinition,Definition of CTO,Chronic total occlusions are defined as occlusions greater than 3(1) month old with angiographic TIMI 0 or TIMI 1 flow,Definition of CTOChronic total,The Spectrum of Lumen Morphology in CTO: Clinical Challenges,Necrotic core,Proteoglycan-rich,Calcification,Large recanalizationchannels,Inflammation,Small recanalizationchannels,Fibrotic plq:Negativeremodelling,The Spectrum of Lumen Morpholo,Chronic Total Occlusions,Whats Blocking up the Lumen?1. Dense Fibrotic Tissue: COLLAGEN!2. Calcification,Chronic Total OcclusionsWhats,Intraluminal Collagen,Extracellular Matrix: Collagen, Calcium,Increased fibrocalcific plaques with ageSrivatsa et al, J Am Coll Cardiol 1997:29:955-63,NCVIntraluminal CollagenExtrac,Intraluminal Calcification,Intraluminal Calcification,Variables related success,Age of OcclusionEntryLengthTortuousityCalciumCollateralsDistal Vessel SizeIn-stent occlusiondevices,Variables related successAge o,Anatomic Descriptorsof Procedural Success,Anatomic Descriptorsof Proced,慢性完全性闭塞的导丝技术介绍课件,慢性完全性闭塞的导丝技术介绍课件,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO GuidewireGuid,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO GuidewireGuid,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 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 (body and tip),Hallmarks of a CTO Guidewire T,ASAHI MIRACLEBROS Family Straight Tip Guide Wires,Characteristics:Core-to-tip design (unique wire drawing process)Non-tapered tip11 cm of radiopacitySmooth tractability & delivery with Joint-less distal coil technologyHydrophobic coatingIncreasing tip loads 3 -12 gmExcellent tip shape ability & shape retention,ASAHI MIRACLEBROS 3ASAHI MIRA,慢性完全性闭塞的导丝技术介绍课件,ASAHI CONFIANZA 9 Tapered Tip Guide Wires,Characteristics:Very stiff tip 9 gm tip loadTapered tip - .009“ (for enhanced penetration)20 cm radiopacitiy - Joint-less technologyHydrophobic coating,ASAHI CONFIANZA 9ASAHI CONFIA,Hydrophilic Coating,0.014”,Radiopaque Spring Coil,0.008”,PTFE,ASAHI CONFIANZA Pro “8-20” Tapered Tip Guide Wire,Characteristics:Stiffest tip - 20 gmTapered tip - .00820 cm radiopacitiy Joint-less technologyHybrid coating,Greatest penetrating force,Hydrophilic Coating0.014”Radi,The combination of a polymer cover and hydrophilic coating provides outstanding lubricity.,Tip coils beneath the polymer help facilitate tip shaping.,HI-TORQUE PILOTTM Family of Guide wire,The combination of a polymer,Cordis SHINOBI & SHINOBI PlusCTO Guidewires,Unique flattened tip designed to cross subtotal occlusions,Flattened radiopaque coils,.0070” Corewire Support,SHINOBI,.0100” Corewire Support,SHINOBI Plus,Cordis SHINOBI & SHINOBI Plus,1. Coronary CTOs have many typesof lesion morphologies.,Therefore, we have to use different types of wiresfor different lesion morphologies.,2. During a single CTO-PCI procedure,we often encounter different kinds of situations.,Therefore, we have to use a different type of wirefor each situation.,Wire selection and wire handling,1. Coronary CTOs have many typ,Guide Wire Selection,Most important considerationsTorque responseTip feel (tactile response)Tip shape curve formation,Guide Wire SelectionMost impor,Hydrophobic vs. Hydrophilic Wires,Hydrophobic wiresProvide better tactile response to operator Provide operator improved tactile response to better navigate micro-channelsTo get into the “dimple” and use tip load to purchase fibrous capHydrophilic wiresHydrophilic wires with tapered tip may improve the locating of micro-channels, however micro-channels can lead to false lumens/sub-intimal spacesHydrophilic wires tend to follow the path of least resistance and generally offer less tip control,Hydrophobic vs. Hydrophilic W,Simplifyed sequence of wires,Easy case ( big vessel, straight )Crossit 100Confianza pro,Difficult case (calcifyed, tortuous, smaller) Miracle 3gProx. Tortuosity: lubricious wiresMiracle 4.5-12 gConfianza wires,Parallel wire: Confianza 6g 12g,Simplifyed sequence of wiresEa,Why so difficult to cross it ?,Why so difficult to cross it ?,Sub-Intimal Path,Sub-Intimal Path,Wire technique for locating another channel Tip Shape Is Key,Wire technique for locating a,Wire tip for CTO,CTO,Stenosis,Tip 1 mm,Tip 2-3mm,Wire tip for CTOCTOStenosisTip,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO GuidewireGuid,Guidewire Operator Techniques,Guidewire Operator TechniquesP,DRILLING(controlled),Guidewire Operator Techniques,Short tip curve ( 2mm) at 45-60o; sometimes a proximal secondary curve at 15-30oControlled rotational tip motion with gentle forward probing Start with moderate stiffness tips and stepwise increases in tip stiffnessPremium on tactile responses,DRILLINGGuidewire Operator Tec,PENETRATION,Guidewire Operator Techniques,Similar tip shape and curves as drilling techniquePrecise movements of the guidewire tipMinimal rotational tip motion with more aggressive directed forward probingTip stiffness should penetrate even heavily calcified entry cap (9-12 gms and tapered)Reduced tactile responsiveness,PENETRATIONGuidewire Operator,Allways steer towards inner curve ! Twist gently , push and pull ! Dont inject dye via OTW-catheter !,Allways steer towards inner cu,In curved vessels, the optimal site for penetrating the fibrous cap is towards the myocardium (mural ),No !,In curved vessels, the optimal,Penetration vs. Controlled Drilling Drilling,Techniques of CTO Guidewire Manipulation,Penetration vs. Controlled Dri,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 “Controlled Drilling”,Techniques of CTO Guidewire Ma,SLIDING,Guidewire Operator Techniques,Longer and shallower tip shapes and no secondary bendsSimultaneous tip rotation and probingAlmost no tactile responseTakes advantage of reduced guidewire surface friction requires polymer cover,SLIDINGGuidewire Operator Tech,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO GuidewireGuid,DRILLING(controlled),CTO Guidewire Categories,Abbott CROSS-IT wires (100, 200,and 300)Asahi-Abbott MIRACLE Bros wiresMedtronic PERSUADER wires (3 and 6 gm),DRILLINGCTO Guidewire Categori,PENETRATION,CTO Guidewire Categories,Abbott CROSS-IT 400 wireAsahi-Abbott CONFIENZA wires (regular and PRO) - 9 and 12 gmMedtronic PERSUADER wire - 9 gm,PENETRATIONCTO Guidewire Categ,SLIDING,CTO Guidewire Categories,Abbott PILOT and Whisper wiresBSC PT wiresCordis SHINOBI wiresAsahi Fielder wires,SLIDINGCTO Guidewire Categorie,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified “Lesion-Specific” CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Anatomy of a CTO GuidewireGuid,DRILLING(controlled),Lesion-Specific CTO Approaches,Most CTOs with discrete entry point;after initial attempt with soft (intermediate) wires“Workhorse” technique,DRILLINGLesion-Specific CTO Ap,PENETRATION,Lesion-Specific CTO Approaches,Blunt entry pointHeavily calcified or resistant lesionsAlternative to “drilling” as workhorse technique after initial soft wire failure,PENETRATIONLesion-Specific CTO,SLIDING,Lesion-Specific CTO Approaches,Microchannels present or sub-total occlusion (residual channel)ISR total occlusionsSome calcified and angulated lesions STAR technique (subintimal reentry),SLIDINGLesion-Specific CTO App,Recent Guidewire Techniques,parallel wire techniques and extra support backup cathetersSesame open,Recent Guidewire Techniques pa,Concept of Parallel Wire Technique,Concept of Parallel Wire Techn,Tortuousity - Lesion on Bend,Tortuousity - Lesion on Bend,慢性完全性闭塞的导丝技术介绍课件,Seesaw: modifyed parallel wire technique,8 F guide2 OTW balloons /catheters2 wires slide parallel and are advanced in an alternating manner,Seesaw: modifyed parallel wire,Seesaw WiringParallel Wire Method with Double Support Catheters,marker,Seesaw WiringParallel Wire Me,Seesaw Wiring,guide wires can exchange their roles as marker or penetrator,marker,Seesaw Wiring guide wires can,CTO at branch:Sesame open (Saito),And entry can still not be found: Sidebranch technique (Katoh),CTO at branch:Sesame open (Sa,Side Branch Technique,Side Branch Technique,Anchoring technique using OTW balloon,Anchoring technique using OTW,Subintimal Tracking and Reentry (STAR)technique,Supportive 8Fr guideCreate or use existing dissection in proximal CTO (Miracle, Confianza, etc.)1.5mm balloon into trackWhisper/Pilot 50 with tight “J” tip/”umbrella tip”Advance with balloon support, avoid spinning wire if possibleMay need pilot 150, 200 for proximalUse softest wire possible for distal (whisper)Reentry,Subintimal Tracking and Reentr,Anterograde Dissection and Reentry,Anterograde Dissection and Ree,Subintimal Tracking and Reentry (STAR)Tips,Stiffer polymer wire (“J”) proximally if needed but always softer distally“J-bend” media-to-media diameterRunoff vessels are keyVisualization of target/runoff vessels is keyReentry strategyDont lose true lumen distal branch, multiple wires if necessaryPTCA pre-stent conservative size, pressures 12 ATMBifurcation stenting only if absolutely necessarySB dissections may be OKDESConsider angiographic followup,Subintimal Tracking and Reentr,Subintimal Tracking and Reentry (STAR)Patient Selection,Failure with conventional wire strategies (parallel, see-saw)No retrograde opportunityRelatively healthy distal vessel beyond CTOMinimal important branches in shear/dissection zone (RCA, OM)Strong clinical indicationThis is final measure, not first measure,Subintimal Tracking and Reentr,Interventional techniques Improvement about CTO,Miracale 1995Conquest 1999Parallel and seesaw 2000IVUS guide 2001STAR 2003SHOOTING and Fielder 2005 Tornus 2005CART 2005,Interventional techniques Impr,Retrograde approach,Anterograde failureBest septal collateral 7F shorter guide catheter 70-90cmACT300 secondsMicrocathter softer and hydrophilic wire,Retrograde approachAnterograde,慢性完全性闭塞的导丝技术介绍课件,CTO Guide Wire Considerations(1),Start with softer guide wiresConsider hydrophilic for sub-total occlusionsConsider hydrophilic for heavy calciumOtherwise, start with soft, hydrophobic wiresAdvance to stiffer wires carefullyConsider parallel wire techniques if subintimalHydrophobic wires offer best tactile feel of lesion,CTO Guide Wire Considerations(,Entry,Unfavorable,Favorable,Stump; no entry point; wire will favor side-branch,Well defined nipple into which wire can be directed,EntryUnfavorableFavorableStump, MIRACLEbros Family Confianza Family,Better torque performance,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 FamilyBetter tor, MIRACLEbros Family Confianza Family,to advance in the hard CTO with tortuosity,to penetrate proximal or 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 over a long distance,particularly in CTO with tortuosity.,Common CTO wire characters(3), MIRACLEbros Familyto advance,Support Catheters,1.5mm balloonTransitILT support catheterSpectronetics Quick Cross St Judes Venture deflecting support catheterTornus catheter,Facilitate wire exchangeImprove torque responseProvide extra backup to the Guidewire,Support Catheters1.5mm balloon,Conquering Chronic Total Coronary Occlusions: newest technical approaches,TornusVibrating penetrating catheter guidewire systemsLaser or radiofrequency ablation,Conquering Chronic Total Coron,慢性完全性闭塞的导丝技术介绍课件,Bottom line for CTO management,1. Before starting, weigh the odds by considering the features of high CTO success based 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 possible, 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.,Bottom line for CTO management,Procedural stopping points :,perforationdevice exit from the anticipated lumenevident futility of success after several hours of effort. fluoroscopic time exceeded 45 minutes, procedure time more than 2 hourscontrast media loads in excess of 500 cc, it would be wise to stop, and if possible, try again on another day,Procedural stopping points :p,慢性完全性闭塞的导丝技术介绍课件,