-Wire Based Strategies- Step by Step Instructions. Yasumi Igarashi M.D. Ph.D. JCHO Hokkaido Hospital
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1 -Wire Based Strategies- Step by Step Instructions Yasumi Igarashi M.D. Ph.D. JCHO Hokkaido Hospital
2 Disclosure Statement of Financial Interest I,Yasumi Igarashi, DO NOT have a financial interest/ arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. All CTO 2015 faculty disclosures are listed on the CRF Events App.
3 Disclosure Statement of Financial Interest 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 ConsulAng Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company no Asahi Intecc/Kaneka Med./AJV/BSJ no no no no no All CTO 2015 faculty disclosures are listed on the CRF Events App.
4 Flow chart of Current CTO PCI Strategy Pre-procedural Examination of Angiogram w/wo MSCT Antegrade approach Retrograde approach 1. Single wire manipulation 1. Wiring through collateral 2. Parallel wire technique 3. IVUS guided wiring 2. Retrograde wiring Contemporary Reverse CART - Under IVUS guidance-
5 CTO guidewires Fielder XT Fielder XT-A Fielder XT-R UlAmatebros Miracle 3 Miracle 6 Miracle 12 Confianza Pro Confianza Pro 12 Confianza Pro 8-20 Gaia 1 st Gaia 2 nd Gaia 3 rd Progress 40 Progress 80 Progress 120 Progress 140T Progress 200T PILOT 50 PILOT 150 PILOT 200 SION SION black SION bleu
6 CTO Guide wire characteristics Tip profile Tip load Dual core Coating Torque penetration Miracle Wire brothers 3G,6G,9G,12G N non excellent fair Tapered floppy wires Fielder XT(R,A) Y/N polymer fair poor Confianza Pro 9,12, N slip poor excellent Gaia 1 st,2 nd,3rd Y slip excellent Good /excellent
7 Antegrade wiring 1) Tapered floppy guidewires 2) Gaia series 3) Confianza family
8 Fielder XTA Polymer Sleeve & SLIP COAT PTFE Coating 0.26mm (0.010 ) Composite core Tip Load 1.0g Radiopacity 16cm Coil 16cm Diameter 0.014inch Tip Diameter 0.010inch Length 190cm 8
9 RCA proximal angurated CTO with take off anomaly
10 Antegrade Single Wire Manipulation Guide Wire: Fielder XT-A
11 Antegrade Single Wire Manipulation Guide Wire: Fielder XT-A
12 Long and diffuse LAD-CTO with shrinked distal true lumen
13 Long and diffuse LAD-CTO with shrinked distal true lumen Fielder XT
14 Long and diffuse LAD-CTO with shrinked distal true lumen
15 Histopathology of CTO lesions Micro channels non- fibrous tissue thrombus
16 Passive wire control Push force Driving force = Push force+resistance inhibition by rotation Passive wire control is not actually controlling the direction
17 Personal CTO crossing strategies (n=127) Failure 9(7.1%) Retrograde Approach 59(46.5%) SWM 43(33.9%) PWT 16(12.6%) Antegrade Approach 59(46.5%)
18 RCA mid CTO case Guide Wire: Fielder XT-A
19 RCA mid CTO case Guide Wire: Fielder XT-A
20 Limitations in floppy tapered polymer wires Poor penetration force Poor torque control - delayed initial torque response (viscoelastic body) - weak torque response in hard plaque Undetectable resistance at wire tip
21 The basic control of chronic occlusion wire passive wire control (loose tissue tracking) active wire control n Torque n Penetration force n Coating (hydrophilic coating, polymer jacket) n Tapered tip
22 Gaia series Total Length 1900mm SLIP COAT coating (Hydro Coating) Length 400mm Coil Length 150mm Gaia First:0.010inch Gaia Second:0.011inch 0.014inch PTFE coating Line-up options allow the operator to choose the appropriate wire for a variety of situations Gaia First Gaia Second Gaia Third Diameter : Tip load :1.5gf Diameter : Tip load :3.5gf Diameter : Tip load :4.5gf
23 The importance of acave wire control and the required wire performance Active wire control Push force Changing the direction by controlling the wire tip with torque. Make a course correction when the wire goes out from the path for wire crossing
24 LAD-CTO with heavy calcium
25 LAD-CTO with heavy calcium CTO Wire escalation :Fielder XTA Gaia 2nd Gaia 3rd
26 RCA long In-stent-occlusion CTO
27 Wire escalation:gaia 2nd Gaia 3rd LAO RAO
28 RCA proximal and distal double CTO
29 RCA proximal and distal double CTO
30 RCA proximal and distal double CTO
31 RCA proximal and distal double CTO
32 RCA proximal CTO and distal double CTO
33 Missing your way, never use Gaia series
34 Bilateral wiring by Miracle brothers(ultimatebros 3G) LAO RAO
35 Bilateral knuckle wiring by Fielder XT-R LAO RAO
36 RCA mid CTO case(2 nd attempt ) in CTO CLUB
37 RCA mid CTO case(2 nd attempt ) in CTO CLUB Penetration of proximal fibrous cap by confianza pro 12G
38 RCA mid CTO case(2 nd attempt ) in CTO CLUB Step down from Confianza Pro12G to Gaia 2nd
39 RCA mid CTO case(2 nd attempt ) in CTO CLUB
40 LAD proximal CTO case in CCT2015 Jailed CTO entry point by previously implanted DES No promising connection channel for retrograde approach
41 Hybrid Strategy
42 Flow chart of Current CTO PCI Strategy Pre-procedural Examination of Angiogram w/wo MSCT Antegrade approach Retrograde approach 1. Single wire manipulation 1. Wiring through collateral 2. Parallel wire technique 3. IVUS guided wiring 2. Retrograde wiring Contemporary Reverse CART - Under IVUS guidance-
43 LAD proximal CTO case in CCT2015
44 Guide wire selecaon Gaia 2nd Confianza Pro 12 Confianza Pro 8-20 Gaia 2nd
45 Flow chart of Current CTO PCI Strategy Pre-procedural Examination of Angiogram w/wo MSCT Antegrade approach Retrograde approach 1. Single wire manipulation 1. Wiring through collateral 2. Parallel wire technique 3. IVUS guided wiring 2. Retrograde wiring Contemporary Reverse CART - Under IVUS guidance-
46 Guide wire selecaon Gaia 2nd Confianza Pro 12 Confianza Pro 8-20 Gaia 2nd Parallell Wire Technique Gaia 3rd Sion Black
47 Guide wire selecaon Gaia 2nd Confianza Pro 12 EscalaAon Confianza Pro 8-20 Gaia 2nd Step down Parallell Wire Technique EscalaAon Gaia 3rd Sion Black Step down
48 Tailor made CTO strategy!!
49 Conclusion Correct understanding of every CTO guidewire s characterisac and performance is the key of CTO PCI success. Floppy tapered wires are sall recommended to be selected as the first choice guidewire. Gaia series are currently the best CTO wires with excellent controllability and penetraaon force. However, CTO operator must take care the risk of wire perforaaon. To achieve and maintain high success rate CTO, operators must make the paaent and lesion based tailor made strategy flexibly in actual CTO PCI pracace.
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