2. Disclosure
• SB: Medtronic, BSc, Abbott
Vascular,Gilead
• Advisory Board: Medtronic, Abbott
Vascular, Philips
• All faculty disclosures are available on
the CRF Events App and online at
www.crf.org/tct
4. Design Characteristics of PTCA Balloons
• Over the wire (OTW)
• Rapid exchange (RX), Monorail
• Perfusion
• Fixed wire
• Cutting balloon
• Scoring balloon-Angiosculpt
5. Over the Wire (OTW)
• Consists of a balloon catheter with a movable guidewire
passing through the entire length of its lumen
• OTW requires 2 operators
• OTW provides better pushability
• 300 cm steerable wire is typically used
• Balloon catheter shafts are typically 145 to 155 cm long
• 25% of the system use in the U.S.
Product diagram courtesy of the manufacturer.
6. Over the Wire (OTW)
Advantages
• Ability to change wire without removing catheter
• Superior pushability because entire catheter body runs
over wire
Disadvantages
• Slightly larger profiles and shaft sizes
• Typically needs 2 operators
• Can take more time, requiring more fluoroscopy
7. Rapid Exchange (RX)
• Guidewire exits balloon catheter several centimeters
proximal to the distal tip
• Guidewire travels separately from the balloon catheter
• RX allows the operator to fix the wire with one hand &
advance the balloon with the other
• Single operator
• 180 through 195 cm steerable guidewire is typically
used
• 75% of the system use in the U.S. and greater than
95% in the remainder of the world
Product diagram courtesy of the manufacturer.
8. Rapid Exchange (RX)
Advantages
• Single operator
• Allows for quick exchanges over a short guidewire
Disadvantages
• Can’t reshape or exchange wire without losing position
• Guidewire difficult to place without support of balloon
• Pushability may be compromised due to the short wire
lumen
9. Balloon Overview
Illustrations are artist’s rendition and are not drawn to scale.
Working
Length
Proximal
Taper
Distal Taper
Tip Length
Tip Entry
Crossing
Profile
10. Balloon Dilatation Catheter
Components
2. Tip
3.
Markers
5. Catheter
Platform
1.
Balloon
4. Distal
Shaft
6. Coating
Illustrations are artist’s rendition and are not drawn to scale.
12. 5 Key Balloon Attributes
• Entry – pushability and crossability
• Tracking – guidewire compatibility
• Crossability – profiles and transition
angles
• Dilatation – balloon material and
shoulders
• Withdrawal – rewrap
13. Definitions
• Nominal - the pressure (in atm.) at which the balloon
reaches its stated size
• Rated Burst Pressure - (RBP) pressure at which 99.9% of
all balloons will not burst at or below (with 95% confidence
interval)
• Working Range - range between nominal and rated burst
pressure
14. Compliance
• Compliant - Diameter increases in ratio with the increase in
inflation force (size of balloon may grow beyond the ceiling
of clinical safety)
• Non-compliant - Reach and maintain specified size
regardless of inflation pressure (little to no flexibility in
vessel sizing)
• Semi-compliant - Wide working pressure range with
controlled flexibility in balloon sizing
17. Marker Bands
• Radiopaque bands are swaggered into the shaft of the
balloon to determine balloon placement under fluoroscopy
• Bands can be either dual markers or a single center marker
Product diagram courtesy of the manufacturer.
19. Balloon Angioplasty Results
• Plain old balloon angioplasty (POBA )has a high rate of acute
recoil and restenosis rates vary from 10-60% depending on size,
diameter, complexity of the lesion and patient related factors.
• The use of the cutting balloon/angioscore have reduced these
rates and may be an option for complex procedures and small
less important branch vessels when stenting is not desired or
to prepare the lesion prior to stenting.
• Currently, PTCA is used traditionally for pre-dilating prior to
stenting and post-dilatiation to maximally expand a stent.
• The era of the drug eluting balloon (DEB) is on the horizon and
will change therapy depending on future randomized trials
22. Guiding Catheter Function
• Conduit for device & wire
transport
• Support for equipment
advancement
• Vehicle for contrast
injection
• Pressure measurement
• Angiographic
assessment
Source: Grossman’s Cardiac Catheterization, Angiography, and Intervention
25. Curve/Tip Length
3.0
4.0
5.0
Judkins
Left
P
S
P = Primary Curve
S = Secondary Curve
Tip Length = P to S distance (cm)
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s
Cardiac Catheterization, Angiography, and Intervention
26. Curve Length
5.0
4.0
3.04
.
0
Lateral Wall Support
3.0
4.0
5.0
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
3.0
4.0
5.0
Tip Orientation
27. Backup Support
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and
Intervention
28. Other Key Features
• Torque and tip control
• Soft tip
• Kink resistance
• Variety of shapes
• Adequate lumen sizes
• Radiopacity
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
29. Access Approach
• Femoral
Extensive physician experience
Easy catheter manipulation
Bleeding at puncture site
• Radial & Brachial
Little physician experience
More difficult catheter manipulation
Infrequent bleeding at puncture site
Other possible complications
Source: The Manual of Interventional Cardiology
38. Core Material
Advantages
• Flexible
• Durable
Disadvantages
• Store torque
• Risk of fracture
NITINOL
Advantages
• Support
• Push
• Torque
Disadvantages
• Kink
• Less flexible
STEEL
39. Wire Coating
HYDROPHILLIC
• attracts water
• It is applied over polymer or
stainless steel (including tip
coils)
• Thin, non-slippery solid when
dry, needs lubrication to
perform
• Becomes gel when wet
• Reduces friction
• Increases trackability
HYDROPHOBIC
• repels water
• Silicone on working area of
wire, excluding tip
• No actuation/wetting required
• Reduces friction
• Increases trackability
40. Guide Wire - Coating
NO COATING
HYDROPHOBIC
HYDROPHILLIC
POLYMER AND
HYDROPHILLIC
TACTILE FEEDBACK
LUBRICITY
41. Guide Wire - Tip
TIP
LOAD
SHAPE
COAT
JOINTS
COILS
DESIGN
43. Wire Selection
Workhorse Wires
• BMW
• BMW Universal
• Runthrough
• Hi-Torque Floppy
• Prowater
Extra Support
• ACS Intermediate
• Choice ES
• Stabilizer
• Wiggle Wire
CTO Wires
• Stiff
Miracle
Confianza
Persuader
• Slippery
Fielder FC,XT
Pilot 50-200
44. Balloons, Guides, Wires
• Core products for the Interventional
cardiology community
• Each product is critical to the ultimate
success of the procedure
• They are used in every case and in many
cases several balloons and wires will be
utilized
• Enhancements to these products occur
regularly and help advance the field
45. Guiding Catheters, Wires, and
Balloons: Equipment and
Results
ABC’s of Interventional Cardiology
TCT 2014
THANK YOU!