Coronary guidewires

1. CORONARY GUIDEWIRES
CHOICE & APPROPRIATE USE IN PCI
Dr Vallabhaneni Sri Ram Bhupal
NIMS,Hyderabad,India

2. CONTENTS
• COMPONENTS OF A GUIDE WIRE
• CLASSIFICATION
• WIRES FOR DIFFERENT OCCASIONS
• GUIDEWIRE MANIPULATION
• COMPLICATIONS

3. •GRUNTZIG First performed Angioplasty in 1974
•1977 – First coronary angioplasty
•Polyvinyl Chloride balloon catheter with short guidewire
attached to its tip

4. •1982 – Simpson reported
First experience with over
the balloon system
•It had an independently
movable guidewire within
the balloon dilation
catheter

5. • To reach far end of the vessel
• To rail the devices into coronaries
• To access the lesion
• To cross the lesion atraumatically
• To provide support for interventional devices

6. 4 KEY characteristics
1. Torque control
Is an ability to apply rotational force at a proximal end of a guidewire and have
that force transmitted efficiently to achieve proper control at the distal end
2. Trackability
Is an ability of a wire to follow the wire tip around curves and bends without
bucking or kinking, to navigate anatomy of vasculature
3. Steerability
Is an ability of a guidewire tip to be delivered to the desired position in a vessel
4. Flexibility
Is an ability to bend with direct pressure

7. Other features
5. Prolapse tendency
Tendency of the body of a wire not to follow the tip around bends
6. Radiopacity/visibility
Is an ability to visualise a guidewire or guidewire tip under fluoroscopy.
7. Tactile feedback
Is tactile sensation on a proximal end of a guide wire that physician has that tells
him what the distal end of the guidewire is doing
8. Crossing
Is an ability of a guidewire to cross lesion with little or no resistance
9. Support
Is an ability of a guidewire to support a passage of another device or system over
it

8. STRUCTURE
 CORE-Material
Diameter
Core taper
 TIP
 COILS, COVERS & COATINGS

9. Core
• Inner part of the guidewire
• Extends through the shaft of the wire from the
proximal to the distal part
• Distal taper
• Stiffest part of the wire that gives stability and
steerability

10. Core Material
Core material affects the flexibility, support, steering
and trackability
• Stainless steel
– superior torque characteristics, can deliver more push,
provides good shapeability and excellent support
– more susceptible to kinking and is less flexible
• Nitinol
– pliable but supportive, less torquability than SS
– generally considered kink resistant & have a tendency to
return to their original shape, making them potentially
less susceptible to deformation during prolonged use

11. Core Diameter
• Influences the performance of the wire
• Larger diameter improves support and allows 1:1
torque response
• Smaller diameter enhances the flexibility
Core taper
• Variable length
• Continuous/segmented
• Short taper and smaller number of wide spaces
gradual tapers increases support and transmission
of push force
• Longer tapers and larger numbers of segmented
tapering increases flexibility

13. Tip
• Tapers distally to a variable extent
– 2-piece core- distal part of core does not reach
distal tip of wire→ shaping ribbon, extends to
distal tip
– 1-piece core- tapered core reaches distal tip.
• 2-piece→ easy shaping & durable shape
memory
• 1-piece →better force transmission to tip &
greater “tactile response” for operator

15. Coils, Covers & Coating
Keeps the diameter at .014 inch
• Coils
– Stainless steel
– Outer coil Design – Coils placed over tapered core and
tip of the wire
– Tip coil Design – Tip alone is covered with coils
– Flexibility, support, steering, tracking, visibility &
tactile feedback
– Radio opaque platinum coils
– Intermediate coils placed on the working length of the
wire

16. Coils

17. Radio-opaque tip
• Visibility of the wire tip is provided by radiopaque
platinum coils that are usually placed at the distal
tip 2 to 3 cm in length, but maybe much longer.
• Galeo Wires – 3 cm distal radio-opaque tip.
• BMW wire – 3 cm distal radio-opaque tip

18. • Covers
– Polymer or plastic
– Lubricity
• Coating
– Distal half
– Affects lubricity and tracking
– Creates tactile feel
– Reduces friction
– Facilitates movement of wire within the vessel and
deliverability of intervention equipment

19. Non-Coated / Hydrophobic wires
Pros
• More controllable (and therefore less likely to dissect)
• Provide better tactile feel
Cons
• Poor trackability
• Wire tip becomes stiffer, torque response increases,
but less tip resistance is transmitted to the operator,
making it easier to enter a false channel.

20. • Hydrophobic coatings are silicone based
coatings which repel water and are applied on
the working length of the wire, with the
exception of the distal tip. They require no
activation by liquids to create a "wax-like"
surface and to achieve the desired effect
— to reduce friction and increase trackability
of the wire. Silicone coating has higher
friction, more stable feel inside the vessel.

21. Hydrophilic
• Applied over the entire working length of wire
including tip coils
• Attracts water - needs lubrication
• Thin, non slippery, solid when dry→ becomes a gel
when wet
– ↓friction
– ↑trackability
– ↓Thrombogenic
↓tactile feel- ↑risk of perforation
Tendency to stick to angioplasty cath
• Useful in negotiating tortuous lesions and in
“finding microchannels” in total occlusions

22. Shapeability and shaping memory
• Shapeability - allows to modify its distal tip
conformation
• Shaping memory - ability of tip to return back
to its basal conformation after having been
exposed to deformation & stress
– Both do not necessarily go in parallel
– SS core wires -easier to shape (↑memory- nitinol
core)
– 2-piece core + shaping ribbon - easier to shape &
↑memory

23. HOW TO CLASSIFY CORONARY
GUIDE WIRES?

24. CLASSIFICATION
• NO UNIFORM CLASSIFICATION
• BUT SOME CATEGORISATION

26. Classification
Based on Tip Flexibility
• Floppy – Eg:- Hi torque balance middle weight, Hi
torque balance,Choice floppy
• Intermediate – Eg:- Hi torque intermediate,
Choice intermediate
• Standard – Shinobi, Boston Scientific
Based on Device support
• Light – Eg:- Hi torque balance
• Moderate – Eg:- Hi torque balance middle Weight
• Extra support – Eg:- Hi torque whisper,Choice

27. “Support”
• Indicator of the core strength
• More stronger the core – more support

28. Floppy
ES – Extra-Support
Grand-Slam
Iron-man

30. Based on coating
• Hydrophilic : Eg:- CholCETM PT Floppy
• Hydrophobic : Eg:- Asahi soft
Depending on tip load
• Floppy, Balanced & Extra support
• Tip load - force needed to bend a wire when
exerted on a straight guide wire tip, at 1 cm
from the tip
– Floppy - <0.5g
– Balanced – 0.5-0.9g
– Extra support - >0.9g

32. BASED ON CLINICAL SCENARIO

35. Commonly Used Workhorse
Guidewires
• ATW/ATW Marker
• Stabilizer
• BMW / BMW Universal
• Zinger
• Cougar XT
• Asahi Light / Medium
• Asahi Standard
• Asahi Prowater Flex
• Choice Floppy
• Luge
• IQ
• Forte Floppy
• Runthrough NS
• Galeo

36. Balance Middleweight Universal wire
(Abbott Vascular/Guidant, Santa Clara, CA)
• Quite steerable - tip is suitable for bending in a “J”
configuration for distal advancement into the distal vessel
bed with minimal trauma while still maintaining some
torque
• shape retention relatively poor -any J configuration tends to
become magnified over time → consequent loss in
steerability
• moderately torquable- progression - minimal friction (light
hydrophilic coating) - Dye injection may also be helpful to
propagate distal advancement
• suitable for rapid, uncomplicated interventions
• low risk to cause dissections/distal perforations
• support - low to moderate

37. CHOICE FLOPPY

38. SELECTION OF GUIDEWIRES FOR
SPECIAL LESIONS

39. The selection of a guidewire
• Essential component
• INFLUENCED BY
• vessel anatomy
• the lesion morphology
• the devices to be used
• operator's experience and preference.

40. LEFT MAIN PCI
• The choice of a guidewire is not of critical
importance.
• Wire selection usually includes spring tip
guidewire designed for frontline lesions, for
example, ChoICE™ Floppy (Boston Scientific),
Hi-Torque Balance Middleweight (Abbott
Vascular)
• FOR LEFT MAIN OR RCA OSTIAL PCI AN
EXTRASUPPORT WIRE IS PREFERED

41. BIFURCATION PCI
• In the presence of difficulties accessing the
side branch some hydrophilic wires such as
the ChoICE™ PT Floppy (Boston Scientific), PT
Graphix™ (Boston Scientific) or Asahi Fielder
(Abbott Vascular) may become useful.

42. • These wires have higher risk to perforate the
distal vessel if allowed to migrate into small
side branches or too distally. Therefore it is
important to monitor the distal position of the
wire tip. These wires also should not to be
jailed because of the risk of wire rupture
during pullback.

43. MAIN VESSEL
TRACKING
Short tapering
better

44. DISSECTIONS
• ChOICE Floppy
• Asahi Soft .
• The parallel wire technique can be
recommended if a dissection plane is entered
with the first wire
• Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi
H, Obara C. The latest wire technique for chronic
total occlusion. Ital Heart J 2005;6:489-93..

45. CALCIFIED LESIONS
• ChoICE Floppy (Boston Scientific).
• If it fails to cross the lesion, the next step is to
choose floppy hydrophilic wire such as the
ChoICE PT Floppy (Boston Scientific) or Asahi
Fielder (Abbott Vascular)

46. TORTUOUS ANATOMY
• Very floppy wire with support for device
delivery could be used
• BMW
• FIELDER FC
• WHISPER ES
• WIGGLE WIRE

49. CTO WIRES

51. CLASSIFICATION OF CTO WIRES

54. CTO guide wire techniques

55. Lesion specific CTO approaches
SLIDING
 Micro-channels present
 CTO’s < 6 months
 ISR total occlusions
 STAR technique
Hydrophilic wires
Fielder,Crosswir
eNT, HT Pilot,
Whisper, Choice
PT

56. Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
entry point after initial attempt
with soft (intermediate wires)
Stiff , hydrophobic
non-tapered wires
MiracleBros (3 g, 4.5 g and
6 g), Persuader (3 g and 6 g)
and Cross-IT XT
(100/200/300)

57. Lesion specific CTO approaches
Penetration
• Blunt entry point
• Heavily calcific or resistant lesions
• Alternative to “drilling” as the
“work horse technique” after initial soft wire failure
Super stiff
tapered wires
Conquest Pro (9 g,
12 g), Cross-IT XT
400, MiracleBros 12

58. GUIDEWIRES FOR RETROGRADE
TECHNIQUES
– Fielder/FielderFC
– X -treme
– Whisper
– ChoICE PT2
– Runthrough / Runthrough Hypercoat

59. COMMONLY USED CTO WIRES

62. Fielder™ / Fielder FC™ (Asahi Intec Co.)
• Special guidewire - distal coil coated with
polymer sleeve & further coated with a
hydrophilic coating
• Provides advanced slip performance &
trackability for highly stenosed lesion & tortuous
vessels
• Very good torque performance
• Combines both slide and torque performance
• Primary wire used in the retrograde technique of
recanalization of CTO

65. Whisper
• Durasteel™ Core-to-tip designed to improve
steering, durable shape retention and tactile
feedback
• Full Polymer cover with Hydrophilic coating
intended for deliverability and smooth lesion
access
• Responsease™ “transitionless” core grind
designed to provide improved tracking and better
torque response
• Tip coils designed to provide softer, shapeable tip
and also improve tactile feedback

66. SUMMARY OF WIRES

67. WORKHORSE WIRES

68. EXTRA SUPPORT WIRES

69. CTO WIRES

70. Guidewire Manipulations
• Two step process
• Shaping the wire tip
– It minimizes the amount of force applied to the
wire
– For steering into the vessel
– For visualization of torquing effort

71. Shaping the Wire Tip

72. Steering of the wire
• Small alternating rotations to left and right
• Excessive rotations should be avoided to
prevent wire tip fracture

73. Optimum guide wire positioning
• Should be placed as distally as possible in the
target vessel
• Allows extra support when crossing with
balloon/stent catheters
• ↓ chance of the wire becoming displaced
backwards across the lesion and necessitating
re-crossing
Avoid vessel perforation when positioning
wires with hydrophilic coatings very distally

74. Strategies if Guidewire fails to cross
• Make the guide more coaxial with the lumen
of the artery
• Use a balloon to direct the wire
• Modify the bend at the tip of the wire
• Change the wire

75. Complications
• Vessel perforations
– Uncommon <1%
– Risk factors
• Hydrophilic wires, core to tip
• Chronic total occlusions
– Diagnosis
• Angiographic diagnosis
• Small extraluminal extravasation of blush in the distribution
of target vessel
• Emergency echo to r/o pericardial effusion and tamponade
– Prognosis
• Extend of extravasation into pericardium

76. –Classification
• Type I – Extraluminal crater without extravasation
• Type II – Containing pericardial or myocardial
blushing
• Type III - having≥ 1 mm diameter with contrast
streaming: and cavity spilling
–Management
• Reversal of anticoagulations
• Prolonged balloon inflation
• PTFE covered stent
• Coil embolization
• Use of gel foams

77. Pseudolesions/Concertina effect
• Stenosis that appears in any artery after the coronary
guidewire is placed in the artery
• Appears in tortuous vessels that have been straightened
out by the guidewire

78. Diagnosis
• Will disappear if the wire is withdrawn
• Replacement of a stiff wire with a flexible floppy
wire eliminates pseudolesion
• Microcatheter or a balloon catheter can be
placed distal to the lesion
Complications
• In some cases cause hemodynamic compromise
and ischemia

80. Guidewire Entrapment
Factors
• Presence of calcified vessels (Eg:- RCA)
• Repeated use of wire for multiple interventions
• Repeated attempts at crossing the same lesion
multiple times with the same wire
• Two wires my become entrapped when the
“Buddy wire” technique is used
• Crossing fresh stent struts

81. Management
• Advance a small profile balloon or a small caliber
catheter (transit catheter) to the attachment site
and pull back gently
• When a second or “buddy wire” gets trapped
between a stent and the vessel wall gentle
traction can be used
• Surgery

82. Guidewire fracture and Embolization
• Risk factors are calcified lesion, bifurcation
stenting and prolonged procedures
• Management
– Surgery
– Snaring the Embolized wire fragment
• The Amplatz Gooseneck Microsnare
• The EnSnare Triple Loop Device
• The X Pro Micro Elite Snare
• The Alligator Retrieval Device
– Push and paste

83. THANK YOU

84. Husband must obey wife but not reverse
• Operator is husband until his guide wire is not
in coronary artery but then you know …..