daniel weilenmann - guidewiresand microcatheters: how to use
TRANSCRIPT
![Page 1: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/1.jpg)
Guidewires and microcatheters: how to use
Daniel Weilenmann, MD FESC FSCAI
Head Interventional Cardiology
Department of Cardiology
Kantonsspital St. Gallen
Switzerland
![Page 2: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/2.jpg)
CTO guidewires
Wire categories
![Page 3: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/3.jpg)
CTO wires
![Page 4: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/4.jpg)
Polymeric wires
![Page 5: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/5.jpg)
Polymer covered wires
FIELDER XT, XT-A or XT-R: Frontline wire for ante- or retrograde channel tracking
FIELDER FC: collateral channel crossing
PILOT 200: antegrad crossing, knuckle wire
![Page 6: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/6.jpg)
Stiff Non-Tapered Jacketed
Pilot 200
• Combination of penetration power and push• Will advance across the path of least resistance
• Follow micro-channels if available• Will cross over into the subintimal space in fibro-
calcific CTOs without microchannels• Manages tortuosity, long lesions well
• Can serve as “knuckle wire”
![Page 7: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/7.jpg)
Non polymeric wires
![Page 8: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/8.jpg)
![Page 9: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/9.jpg)
![Page 10: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/10.jpg)
![Page 11: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/11.jpg)
Externalization wires
Pilot 200 bigger knuckles
Fielder XT smaller knuckles
Knuckle wires (blunt dissection)
RG3
R350
Viper
![Page 12: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/12.jpg)
Knuckle wires (blunt dissection)
![Page 13: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/13.jpg)
Guidewires : how to use
The task-specific approach
![Page 14: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/14.jpg)
Coronary guide-wires: classification
Buller, MLCTO Nice 2016
Conventional
workhorse-wires
Support-wires
CTO-wires
Conventional
workhorse-wires
Support-wires
CTO-wires
![Page 15: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/15.jpg)
Coronary guide-wires: classification
Buller, MLCTO Nice 2016
Conventional
workhorse-wires
Support-wires
CTO-wires
Conventional
workhorse-wires
Support-wires
CTO-wires
Task-Specific
access
directed penetration
microchannel
collateral crossing
fenestration re-entry
knuckling
externalization
Task-Specific
access
directed penetration
microchannel
collateral crossing
fenestration re-entry
knuckling
externalization
![Page 16: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/16.jpg)
Guidewires and microcatheters: how to use
A task-specific approach
CTO anatomy
![Page 17: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/17.jpg)
J-CTO score
• Proximal cap
• Intra CTO Calcium
• In-CTO tortuosity
• Lesion length
• Previous procedural failure
J-CTO score: Morino et al. JACC Interv 2011; 4: 213 - 21
![Page 18: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/18.jpg)
Hybrid Algorithm:
task specific wire approach
Wilson et al. Heart 10th May 2016
![Page 19: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/19.jpg)
Hybrid Algorithm:
task specific wire approach
Wilson et al. Heart 10th May 2016
![Page 20: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/20.jpg)
Predictors of success for A/RWE
• Short lesion length
• cap tapered (or blunt)
• No or low tortuosity
![Page 21: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/21.jpg)
Wire based strategies
Microchannels:
taperd polymeric wires
Fielder XT
Fielder XT-A or XT-R
Penetration:Stiffer tapered wires
Conquest PRO 9/12
Hornet
GAIA 2 or 3
Progress 140/200
Stiffer non tapered wires
Pilot 200
Tortuosity:Soft polymeric wires Stiffer tapered wires
Tend to bend Risk of perforation
Microchannel No microchannel Tortuosity – long occluded segment
![Page 22: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/22.jpg)
Antegrade wire strategies
Microchannels:taperd polymeric wires
Fielder XT
Fielder XT-A or XT-R
Penetration:Stiffer tapered wires
Conquest PRO 9/12
Hornet 14
GAIA 2 or 3
Progress 140/200
Stiffer non tapered wires
Pilot 200
Knuckling wires:Fielder XT (smaller) Pilot 200 (bigger)
Microchannel No microchannel Tortuosity – long occluded segment
![Page 23: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/23.jpg)
Retrograde wire strategies
Retrograde Passage/Externialisation
Retrograde knuckle
Extension of the dissection
“LANDMARK WIRE”
Retrograde wire
Antegrade wire
Reverse CART
CART
![Page 24: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/24.jpg)
Guidewires : how to use
The wire manipulation
![Page 25: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/25.jpg)
CTO wire manipulation: CTO bend
![Page 26: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/26.jpg)
CTO wire manipulation
![Page 27: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/27.jpg)
CTO wire manipulation
Sartoru Sumitsuij JACC Interv 2011
![Page 28: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/28.jpg)
Drilling
![Page 29: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/29.jpg)
CONFIANZA PRO 12: punture
![Page 30: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/30.jpg)
CONFIANZA PRO 12: punture
![Page 31: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/31.jpg)
CTO wire manipulation
![Page 32: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/32.jpg)
GAIA: deflection and rotation
![Page 33: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/33.jpg)
GAIA: deflection and rotation
![Page 34: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/34.jpg)
CTO crossing: wire based approach
Fielder XT
Pilot 200 or GAIA
Confianza PRO 12
Hornet 15
Progress 200
![Page 35: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/35.jpg)
Collateral channel crossing
Septal
Septal-Septal
Epicardial- Dg
Epicardial-Apical
Conus-Septal
Epi (OM to Dg or Dg to Dg)
Etc.
![Page 36: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/36.jpg)
Collateral channel crossing
SUOH ?
![Page 37: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/37.jpg)
Collateral crossing: septals
Possible sequence
“Collateral Crossing”
SION
SION Black (FFC)
XTR (FXT)
![Page 38: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/38.jpg)
Collateral crossing: epicardial
Possible sequence for
“Epicardial
Collateral Crossing”
SION
SUOH ?
![Page 39: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/39.jpg)
![Page 40: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/40.jpg)
Collateral crossing: which wire?
Tsuchikane, Euro CTO Club 2015 in Istanbul
![Page 41: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/41.jpg)
![Page 42: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/42.jpg)
Microcatheters: how to use
![Page 43: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/43.jpg)
Guidewire and microcatheter
![Page 44: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/44.jpg)
Microcatheters : what is on the market ?
ASAHI INTECC: Corsair
Caravel
Terumo: Finecross
Vascular solution: Turnpike family
Turnpike LP
Acrostak: Mcath
![Page 45: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/45.jpg)
CORSAIR
![Page 46: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/46.jpg)
CORSAIR
![Page 47: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/47.jpg)
CORSAIR
![Page 48: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/48.jpg)
Caravel
![Page 49: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/49.jpg)
CARAVEL
![Page 50: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/50.jpg)
Microcatheters - FineCross
![Page 51: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/51.jpg)
Soft Tip
• Spiral
– Outer coil on the distal shaft for added
rotational advancement
– Increased stability during knuckling in
resistant lesions
– Vessels with > 1.0 mm DS
Turnpike
catheter
![Page 52: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/52.jpg)
Soft Tip
• LP
– Lower profile and increased flexibility
compared with turnpike
– Ideal for crossing epicardials
Turnpike
catheter
![Page 53: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/53.jpg)
• CenterCross– Self-expanding anchor
– Coaxial alignment
– Central 3F lumen
Amplified Support – Anchoring and Centering
Simplified Luminal Crossing
Scaffold
MicrocatheterInner Shaft
Outer Sheath
Guidewire
Technical specs:Up to 4+mm native vesselsOTW guidewire lumen3F microcatheter compatible
o Corsair, TruePath, Viance
0.035” GW compatible for peripheral7Fr guide compatible (5F sheath)130 cm working length
![Page 54: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/54.jpg)
Guidewire Access Selectively Deliver
Support Side Branch Contrast/Drug
Twin Pass: Dual access catheter
![Page 55: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/55.jpg)
![Page 56: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/56.jpg)
![Page 57: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/57.jpg)
Advance and retrieve the microcath
Distal RCA
Septal CC
![Page 58: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/58.jpg)
Ambiguous proximal cap?
Interventional collateral
channel or graft?
Start retrograde
Lesion length > 20 mm?
Retrograde
Dissection
Re-entry
(RDR)
True-to-true
(TTT)
a) Antegrade balloon-assisted
RDR (reverse CART)
b) Mother-and-Child and balloon-
assisted RDR
c) Retrograde balloon-assisted RDR
(or CART)
d) Wire-based RDR (with wires
only)
Expanded Hybrid CTO Crossing Algorithm
Sequential
wires (or WE)
YesNo
Major side branch at distal
cap or disease at distal
target?
Start antegrade
Lesion length > 20 mm?
Antegrade
Dissection
Re-entry (ADR)
a) Sequential wires (or
WE)
b) Device-based
(CrossBoss® for in-
stent restenosis or
native CTO TTT
crossing)
a) Device-based
CrossBoss® and
Stingray® system
Alternatively
b) Wire-based (STAR,
contrast-guided
STAR, mini-STAR,
LAST)
NoStart antegrade
Good segment for re-entry?
BASE (Balloon-
Assisted
Subintimal
Entry)
or
‘Scratch and
go’ technique
IVUS-guided
puncture for
TTT crossing
or
MDCT-guided
puncture for
TTT crossing
Yes
No
True-to-true
(TTT)
Yes
Yes
Yes
YesNo
No
No
Clear proximal cap?Yes No
Rinfret S. Percutaneous Intervention for Coronary Chronic Total Occlusion: the Hybrid approach
1st ed. Springer International Publishing, 2016
![Page 59: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/59.jpg)
Hybrid algorithm: strategies
50%
![Page 60: Daniel Weilenmann - Guidewiresand microcatheters: how to use](https://reader034.vdocuments.us/reader034/viewer/2022042723/58ee7a9b1a28ab2d018b468d/html5/thumbnails/60.jpg)
Thank you