Advanced Wiring Techniques for Complex femoropopliteal

Advanced Wiring Techniques for Complex femoropopliteal

Obstructions

Hiroyoshi Yokoi, MD

Fukuoka Sanno Hospital

Fukuoka, Japan

Disclosure

Speaker name:

..................Hiroyoshi Yokoi...............................................................

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s) Cook, Termo, BSJ,BIRD

I do not have any potential conflict of interest

☒

Geographical Scope of EVT Physicians

North America

• 40% VS• 40% IC• 20% IR

Europe

• 30% IC• 50% IR• 20% VS

• 10% IC• 15% IR• 75% VS

• 10% IC• 70% IR• 20% VS

• 30% IC• 35% IR• 35% VS

Asia-Pacific

• 10% IC• 30% IR• 60% VS

• 80% IC• 5% IR• 15% VS

Latin America

• 20% IC• 30% IR• 50% VS

IC; Interventional Cardiologist IR; Interventional RadiologistVS; Vascular Surgeon

• 80% IC• 5% IR• 15% VS

Japanese EVT-CTO wiring techniques developed from PCI

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Which wire is appropriate for CTO ?

0.014 or 0.018 or 0.035

In Japan, 0.014-0.018 inch guidewire is favorable than

0.035-inch guidewire in CTO intervention

BTK/SFA SFA/Iliac SFA/Iliac

How I shape the tip of guidewires?

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

First choice & main GW

Polymer-jacketed GW

・ Regalia XS 1.0・ Chevalier・ Command・ Jupiter FC

Standard GW for SFA&BTK intervention

Regalia XS 1.0 (Asahi Intecc)

Chevalier 14 Floppy

0.014inch

Radiopaque length 3cm

Polymer Jacket（Coil Inside）12cm

Total length：235cm

PTFE CoatingHydrophilic Coating

Tip weight: 2g

Strong point is “Trackability”Stainless steal shaft

Super strong durability

Hi-Torque Command (Abbot)

Coil length：8 cm

Hydrophilic coating length：55cm

0.014inch

Total length：235 cm

不透過長：3 cm

NiTi Core Shaft : 55cm SUS Core Shaft

Polymer coating length：39cm(invisible polymer)

Hybrid core system（Niti+SUS）Polymer Jacket

Hydrophilic coating

Differences in each PJ-GWs

・ Regalia XS 1.0Basic GW , Safe, Poor durability

・ Chevalier floppyControllable GW; Good Trackability & Pushability

・ HT-CommandStrong durability but slightly stiff (Tip weight; 3g)

・ Jupiter FC/ FC3Balanced （Trackability, pushability & Durability）

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Treasure is a hydrophilic coated 0.014-0.018” PTA guidewire, which possesses superior torqueability due to its structure using thick stainless steel wires for the spring coil.

70mm 80mm 0.018 inch

150mm (Pt Coil)Hydrophilic Coating PTFE Coating

12g

High torque performance

Good for controlled drilling

From June 2004

Detailed characteristics

Composite Core

Micro-cone tip

Tip load 12gf

Balanced power to cross the highly resistant lesions

Mini pre-shape

Balanced support shaft

design

Torque response

Penetrability

Shape retention

Push transmission Easily catches the entry point

of the occluded lesion

Easy directional control

Advantages in the occluded lesion

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Astato is a 0.014-0.018” hydrophilic coated PTA guidewire, which possesses high penetration power with its 30g tip load and tapered design down to 0.013”.

0.013inch0.013inch

30g150mm (Pt Coil)

Hydrophilic coating

High penetration force

Good for penetration

From August 2006

Radiopaque 3cm0.014inch

PTFE CoatingHydrophilic Coating

Length：190cm : SUS core

Tip load 45g,100g

25°1mm pre-shaped

Jupiter MAX product spec.

CTO Wire Escalation Techniques

Hybrid Sliding-Drilling-Penetration

Sliding (if micro-channel present)

(Polymer jacketed guidewire)

↓Not cross

Controlled Drilling

(Treasure XS 12, Halberd)

↓Not cross

Penetrating

(Astato XS 30,Jupiter 45,MAX)

↓Not cross

Retrograde Approach

Intraluminal vs. subintimal

All the effort we do for getting the intraluminal space

using several techniques and devices.

Rapid Exchange Lumen & OTW Lumen

Dual Lumen Catheter

Rapid Exchange Lumen(0.014inch)

OTW Lumen（0.014inch)

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Any distribution, copying or forwarding is strictly prohibited.

AMC-K14095

Micro-cone tipTip load 7.5gf

Deflection and directional control with the balanced penetration force and torque response

Deflection control

Balanced support shaft

design

Composite Core Torque response

Penetration

Push transmission Easily catches the entry point

of the occluded lesion

Easy directional control

Advantages in the occluded lesion

Detailed characteristics

Mini pre-shape Shape retention

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Scenery of Cath-Laboduring Ultrasound Guided EVT

by courtesy of Miyamoto

Guidewire Crossing of CTOsunder Ultrasound Guidance

SFA Just CTO 0.014inch GW

by courtesy of Miyamoto

To identify in which direction the true

lumen is present.

IVUS-guided parallel wiring

CTO-exit

wire preceding

IVUS-guided technique for long SFA CTO

Prox

Mid

Dis

IVUS

preceding

wire preceding

wire preceding IVUS preceding

or

((((

(((( ((((

((((

IVUS preceding

SFA-proximal to mid

by courtesy of Kawasaki

Wire preceding

by courtesy of Kawasaki

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Peroneal puncture Metatarsal puncture Plantar puncture

Take Home Message

• EVT for SFA- CTOs is still technically developing.

• Generally, we have to be very flexible to change

our strategy during EVT.

• We have to be familiar with all of the techniques,

which have been developed.

Advanced Wiring Techniques for Complex femoropopliteal

Obstructions

Hiroyoshi Yokoi, MD

Fukuoka Sanno Hospital

Fukuoka, Japan