Guidewires and microcatheters: how to use

Daniel Weilenmann, MD FESC FSCAI

Head Interventional Cardiology

Department of Cardiology

Kantonsspital St. Gallen

Switzerland

CTO guidewires

Wire categories

CTO wires

Polymeric wires

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

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”

Non polymeric wires

Externalization wires

Pilot 200 bigger knuckles

Fielder XT smaller knuckles

Knuckle wires (blunt dissection)

RG3

R350

Viper

Knuckle wires (blunt dissection)

Guidewires : how to use

The task-specific approach

Coronary guide-wires: classification

Buller, MLCTO Nice 2016

Conventional

workhorse-wires

Support-wires

CTO-wires

Conventional

workhorse-wires

Support-wires

CTO-wires

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

Guidewires and microcatheters: how to use

A task-specific approach

CTO anatomy

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

Hybrid Algorithm:

task specific wire approach

Wilson et al. Heart 10th May 2016

Hybrid Algorithm:

task specific wire approach

Wilson et al. Heart 10th May 2016

Predictors of success for A/RWE

• Short lesion length

• cap tapered (or blunt)

• No or low tortuosity

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

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

Retrograde wire strategies

Retrograde Passage/Externialisation

Retrograde knuckle

Extension of the dissection

“LANDMARK WIRE”

Retrograde wire

Antegrade wire

Reverse CART

CART

Guidewires : how to use

The wire manipulation

CTO wire manipulation: CTO bend

CTO wire manipulation

CTO wire manipulation

Sartoru Sumitsuij JACC Interv 2011

Drilling

CONFIANZA PRO 12: punture

CONFIANZA PRO 12: punture

CTO wire manipulation

GAIA: deflection and rotation

GAIA: deflection and rotation

CTO crossing: wire based approach

Fielder XT

Pilot 200 or GAIA

Confianza PRO 12

Hornet 15

Progress 200

Collateral channel crossing

Septal

Septal-Septal

Epicardial- Dg

Epicardial-Apical

Conus-Septal

Epi (OM to Dg or Dg to Dg)

Etc.

Collateral channel crossing

SUOH ?

Collateral crossing: septals

Possible sequence

“Collateral Crossing”

SION

SION Black (FFC)

XTR (FXT)

Collateral crossing: epicardial

Possible sequence for

“Epicardial

Collateral Crossing”

SION

SUOH ?

Collateral crossing: which wire?

Tsuchikane, Euro CTO Club 2015 in Istanbul

Microcatheters: how to use

Guidewire and microcatheter

Microcatheters : what is on the market ?

ASAHI INTECC: Corsair

Caravel

Terumo: Finecross

Vascular solution: Turnpike family

Turnpike LP

Acrostak: Mcath

CORSAIR

CORSAIR

CORSAIR

Caravel

CARAVEL

Microcatheters - FineCross

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

Soft Tip

• LP

– Lower profile and increased flexibility

compared with turnpike

– Ideal for crossing epicardials

Turnpike

catheter

• 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

Guidewire Access Selectively Deliver

Support Side Branch Contrast/Drug

Twin Pass: Dual access catheter

Advance and retrieve the microcath

Distal RCA

Septal CC

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

Hybrid algorithm: strategies

50%

Thank you