慢性完全性闭塞的导丝技术介绍.ppt

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1、Introduction wire techniques of chronic total occlusions,Jun Dai,M.D.Coronary disease center Fuwai Hospital CAMS&PUMC Beijing,Contents,DefinitionPathologyAngiography imagingPCI technical challenge guidewire technology interventional devices revascularization technology,Definition of CTO,Chronic tota

2、l 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 recanalizationchannels,Inflammation,Small recanalizationchannels,Fibrotic plq:Nega

3、tiveremodelling,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 Calcification,Variabl

4、es related success,Age of OcclusionEntryLengthTortuousityCalciumCollateralsDistal Vessel SizeIn-stent occlusiondevices,Anatomic Descriptorsof Procedural Success,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified“Lesion-Specific”CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO G

5、uidewire 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 tapered Coils and covers-some favor increased radio

6、pacity;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 hydr

7、ophobic for torque response(body and tip),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 3-1

8、2 gmExcellent tip shape ability&shape retention,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,Hydrophilic Coating,0.014”,Radiopaque Spring Coil,0.008”,PTFE,A

9、SAHI CONFIANZA Pro“8-20”Tapered Tip Guide Wire,Characteristics:Stiffest tip-20 gmTapered tip-.00820 cm radiopacitiy Joint-less technologyHybrid coating,Greatest penetrating force,The combination of a polymer cover and hydrophilic coating provides outstanding lubricity.,Tip coils beneath the polymer

10、help facilitate tip shaping.,HI-TORQUE PILOTTM Family of Guide wire,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,1.Coronary CTOs have many typesof les

11、ion 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,Guide Wire

12、 Selection,Most important considerationsTorque responseTip feel(tactile response)Tip shape curve formation,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”

13、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,

14、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,Why so difficult to cross it?,Sub-Intimal Path,Wire technique for loc

15、ating 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 Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,Guidewire Operator Techniques,DRILLING(controlled),Gu

16、idewire 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,PENETRATION,Guidewire Operator T

17、echniques,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,Allways ste

18、er 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 the myocardium(mural),No!,Penetration vs.Controlled Drilling Drilling,Techniques of CTO Guidewire Manipulation,Techniques of CTO Guidewire

19、 Manipulation,Penetration vs.Controlled Drilling,Directional control of the tip is more precise in“Penetration”,Advancement of the tip is easier in“Controlled Drilling”,SLIDING,Guidewire Operator Techniques,Longer and shallower tip shapes and no secondary bendsSimultaneous tip rotation and probingAl

20、most no tactile responseTakes advantage of reduced guidewire surface friction requires polymer cover,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified“Lesion-Specific”CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,DRILLING(controlled),CTO Guidewire Categ

21、ories,Abbott CROSS-IT wires(100,200,and 300)Asahi-Abbott MIRACLE Bros wiresMedtronic PERSUADER wires(3 and 6 gm),PENETRATION,CTO Guidewire Categories,Abbott CROSS-IT 400 wireAsahi-Abbott CONFIENZA wires(regular and PRO)-9 and 12 gmMedtronic PERSUADER wire-9 gm,SLIDING,CTO Guidewire Categories,Abbott

22、 PILOT and Whisper wiresBSC PT wiresCordis SHINOBI wiresAsahi Fielder wires,Anatomy of a CTO Guidewire,Guidewire Operator Techniques,Simplified“Lesion-Specific”CTO Guidewire Use Algorithms,CTO Guidewire Design,CTO Guidewire Categories,DRILLING(controlled),Lesion-Specific CTO Approaches,Most CTOs wit

23、h discrete entry point;after initial attempt with soft(intermediate)wires“Workhorse”technique,PENETRATION,Lesion-Specific CTO Approaches,Blunt entry pointHeavily calcified or resistant lesionsAlternative to“drilling”as workhorse technique after initial soft wire failure,SLIDING,Lesion-Specific CTO A

24、pproaches,Microchannels present or sub-total occlusion(residual channel)ISR total occlusionsSome calcified and angulated lesions STAR technique(subintimal reentry),Recent Guidewire Techniques,parallel wire techniques and extra support backup cathetersSesame open,Concept of Parallel Wire Technique,To

25、rtuousity-Lesion on Bend,Seesaw:modifyed parallel wire technique,8 F guide2 OTW balloons/catheters2 wires slide parallel and are advanced in an alternating manner,Seesaw WiringParallel Wire Method with Double Support Catheters,marker,Seesaw Wiring,guide wires can exchange their roles as marker or pe

26、netrator,marker,CTO at branch:Sesame open(Saito),And entry can still not be found:Sidebranch technique(Katoh),Side Branch Technique,Anchoring technique using OTW balloon,Subintimal Tracking and Reentry(STAR)technique,Supportive 8Fr guideCreate or use existing dissection in proximal CTO(Miracle,Confi

27、anza,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,Anterograde Dissection and Reentry,Subintimal Tracking and Reentry(STA

28、R)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

29、 ATMBifurcation stenting only if absolutely necessarySB dissections may be OKDESConsider angiographic followup,Subintimal Tracking and Reentry(STAR)Patient Selection,Failure with conventional wire strategies(parallel,see-saw)No retrograde opportunityRelatively healthy distal vessel beyond CTOMinimal

30、 important branches in shear/dissection zone(RCA,OM)Strong clinical indicationThis is final measure,not first measure,Interventional techniques Improvement about CTO,Miracale 1995Conquest 1999Parallel and seesaw 2000IVUS guide 2001STAR 2003SHOOTING and Fielder 2005 Tornus 2005CART 2005,Retrograde ap

31、proach,Anterograde failureBest septal collateral 7F shorter guide catheter 70-90cmACT300 secondsMicrocathter softer and hydrophilic wire,CTO Guide Wire Considerations(1),Start with softer guide wiresConsider hydrophilic for sub-total occlusionsConsider hydrophilic for heavy calciumOtherwise,start wi

32、th soft,hydrophobic wiresAdvance to stiffer wires carefullyConsider parallel wire techniques if subintimalHydrophobic 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 F

33、amily 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 Family Confianza Family,to advance in the hard CTO

34、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

35、 seek the true channel or advance over a long distance,particularly in CTO with tortuosity.,Common CTO wire characters(3),Support Catheters,1.5mm balloonTransitILT support catheterSpectronetics Quick Cross St Judes Venture deflecting support catheterTornus catheter,Facilitate wire exchangeImprove to

36、rque responseProvide extra backup to the Guidewire,Conquering Chronic Total Coronary Occlusions:newest technical approaches,TornusVibrating penetrating catheter guidewire systemsLaser or radiofrequency ablation,Bottom line for CTO management,1.Before starting,weigh the odds by considering the featur

37、es 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 guidewir

38、e.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.,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,