慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件

1、Introduction wire techniques of chronic total occlusionsJun Dai , M.D. Coronary disease center Fuwai Hospital CAMS & PUMC BeijingIntroduction wire techniques ContentsDefinitionPathologyAngiography imagingPCI technical challenge guidewire technology interventional devices revascularization technology

2、ContentsDefinitionDefinition of CTOChronic total occlusions are defined as occlusions greater than 3(1) month old with angiographic TIMI 0 or TIMI 1 flowDefinition of CTOChronic totalThe Spectrum of Lumen Morphology in CTO: Clinical ChallengesNecrotic coreProteoglycan-richCalcificationLarge recanali

3、zationchannelsInflammationSmall recanalizationchannelsFibrotic plq:NegativeremodellingThe Spectrum of Lumen MorpholoChronic Total OcclusionsWhats Blocking up the Lumen?1. Dense Fibrotic Tissue: COLLAGEN!2. CalcificationChronic Total OcclusionsWhatsNCVIntraluminal CollagenExtracellular Matrix: Collag

4、en, CalciumIncreased fibrocalcific plaques with ageSrivatsa et al, J Am Coll Cardiol 1997:29:955-63NCVIntraluminal CollagenExtrac Intraluminal Calcification Intraluminal CalcificationVariables related successAge of OcclusionEntryLengthTortuousityCalciumCollateralsDistal Vessel SizeIn-stent occlusion

5、devicesVariables related successAge oAnatomic Descriptorsof Procedural SuccessAnatomic Descriptorsof Proced慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件Anatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnat

6、omy of a CTO GuidewireGuidAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnatomy of a CTO GuidewireGuidHallmarks of a CTO Guidewire Tip styles - core-to-tip designs; sometimes tapered Coils

7、and covers - some favor increased radiopacity; jointless coils for improved torque response; polymer covers for selected applications Core tapers and materials - shorter tapers for improved torque response; generally stainless steel Core diameters - larger for increased support and torque response C

8、oatings - hydrophilic for tracking (body) and hydrophobic for torque response (body and tip)Hallmarks of a CTO Guidewire TASAHI MIRACLEBROS 3ASAHI MIRACLEBROS 4.5ASAHI MIRACLEBROS 6ASAHI MIRACLEBROS 12ASAHI MIRACLEBROS Family Straight Tip Guide WiresCharacteristics:Core-to-tip design (unique wire dr

9、awing process)Non-tapered tip11 cm of radiopacitySmooth tractability & delivery with Joint-less distal coil technologyHydrophobic coatingIncreasing tip loads 3 -12 gmExcellent tip shape ability & shape retentionASAHI MIRACLEBROS 3ASAHI MIRA慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件ASAHI CONFIANZA 9ASAHI CONFIANZA 9 Tapered T

10、ip Guide WiresCharacteristics:Very stiff tip 9 gm tip loadTapered tip - .009“ (for enhanced penetration)20 cm radiopacitiy - Joint-less technologyHydrophobic coating ASAHI CONFIANZA 9ASAHI CONFIA Hydrophilic Coating0.014”Radiopaque Spring Coil0.008”PTFEASAHI CONFIANZA Pro “8-20” Tapered Tip Guide Wi

11、reCharacteristics:Stiffest tip - 20 gmTapered tip - .00820 cm radiopacitiy Joint-less technologyHybrid coating Greatest penetrating force Hydrophilic Coating0.014”Radi The combination of a polymer cover and hydrophilic coating provides outstanding lubricity. Tip coils beneath the polymer help facili

12、tate tip shaping.HI-TORQUE PILOTTM Family of Guide wire The combination of a polymer Cordis SHINOBI & SHINOBI PlusCTO GuidewiresUnique flattened tip designed to cross subtotal occlusionsFlattened radiopaque coils.0070” Corewire SupportSHINOBI.0100” Corewire SupportSHINOBI PlusCordis SHINOBI & SHINOB

13、I Plus1. Coronary CTOs have many typesof lesion morphologies.Therefore, we have to use different types of wiresfor different lesion morphologies.2. During a single CTO-PCI procedure,we often encounter different kinds of situations.Therefore, we have to use a different type of wirefor each situation.

14、Wire selection and wire handling1. Coronary CTOs have many typGuide Wire SelectionMost important considerationsTorque responseTip feel (tactile response)Tip shape curve formationGuide Wire SelectionMost imporHydrophobic vs. Hydrophilic WiresHydrophobic wiresProvide better tactile response to operato

15、r Provide operator improved tactile response to better navigate micro-channelsTo get into the “dimple” and use tip load to purchase fibrous capHydrophilic wiresHydrophilic wires with tapered tip may improve the locating of micro-channels, however micro-channels can lead to false lumens/sub-intimal s

16、pacesHydrophilic wires tend to follow the path of least resistance and generally offer less tip controlHydrophobic vs. Hydrophilic WSimplifyed sequence of wiresEasy case ( big vessel, straight )Crossit 100Confianza proDifficult case (calcifyed, tortuous, smaller) Miracle 3gProx. Tortuosity: lubricio

17、us wiresMiracle 4.5-12 gConfianza wiresParallel wire: Confianza 6g 12gSimplifyed sequence of wiresEaWhy so difficult to cross it ?Why so difficult to cross it ?Sub-Intimal PathSub-Intimal PathWire technique for locating another channel Tip Shape Is KeyWire technique for locating aWire tip for CTOCTO

18、StenosisTip 1 mmTip 2-3mmWire tip for CTOCTOStenosisTipAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnatomy of a CTO GuidewireGuidGuidewire Operator TechniquesPENETRATIONDRILLING(controlle

19、d) SLIDINGGuidewire Operator TechniquesPDRILLING(controlled)Guidewire Operator Techniques Short tip curve ( 2mm) at 45-60o; sometimes a proximal secondary curve at 15-30oControlled rotational tip motion with gentle forward probing Start with moderate stiffness tips and stepwise increases in tip stif

20、fnessPremium on tactile responsesDRILLINGGuidewire Operator TecPENETRATIONGuidewire Operator Techniques Similar tip shape and curves as drilling techniquePrecise movements of the guidewire tipMinimal rotational tip motion with more aggressive directed forward probingTip stiffness should penetrate ev

21、en heavily calcified entry cap (9-12 gms and tapered)Reduced tactile responsivenessPENETRATIONGuidewire Operator Allways steer towards inner curve ! Twist gently , push and pull ! Dont inject dye via OTW-catheter !Allways steer towards inner cuIn curved vessels, the optimal site for penetrating the

22、fibrous cap is towards the myocardium (mural ) No !In curved vessels, the optimalPenetration vs. Controlled Drilling DrillingTechniques of CTO Guidewire ManipulationPenetration vs. Controlled DriTechniques of CTO Guidewire ManipulationPenetration vs. Controlled DrillingDirectional control of the tip

23、 is more precise in “Penetration”Advancement of the tip is easier in “Controlled Drilling”Techniques of CTO Guidewire MaSLIDINGGuidewire Operator Techniques Longer and shallower tip shapes and no secondary bendsSimultaneous tip rotation and probingAlmost no tactile responseTakes advantage of reduced

24、 guidewire surface friction requires polymer cover SLIDINGGuidewire Operator TechAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnatomy of a CTO GuidewireGuidDRILLING(controlled)CTO Guidewir

25、e Categories Abbott CROSS-IT wires (100, 200,and 300)Asahi-Abbott MIRACLE Bros wiresMedtronic PERSUADER wires (3 and 6 gm)DRILLINGCTO Guidewire CategoriPENETRATIONCTO Guidewire Categories Abbott CROSS-IT 400 wireAsahi-Abbott CONFIENZA wires (regular and PRO) - 9 and 12 gmMedtronic PERSUADER wire - 9

26、 gmPENETRATIONCTO Guidewire CategSLIDINGCTO Guidewire Categories Abbott PILOT and Whisper wiresBSC PT wiresCordis SHINOBI wiresAsahi Fielder wiresSLIDINGCTO Guidewire CategorieAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewi

27、re DesignCTO Guidewire CategoriesAnatomy of a CTO GuidewireGuidDRILLING(controlled)Lesion-Specific CTO Approaches Most CTOs with discrete entry point;after initial attempt with soft (intermediate) wires“Workhorse” techniqueDRILLINGLesion-Specific CTO ApPENETRATIONLesion-Specific CTO Approaches Blunt

28、 entry pointHeavily calcified or resistant lesionsAlternative to “drilling” as workhorse technique after initial soft wire failure PENETRATIONLesion-Specific CTOSLIDINGLesion-Specific CTO Approaches Microchannels present or sub-total occlusion (residual channel)ISR total occlusionsSome calcified and

29、 angulated lesions STAR technique (subintimal reentry)SLIDINGLesion-Specific CTO AppRecent Guidewire Techniques parallel wire techniques and extra support backup cathetersSesame open Recent Guidewire Techniques paConcept of Parallel Wire TechniqueConcept of Parallel Wire TechnTortuousity - Lesion on

30、 BendTortuousity - Lesion on Bend慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件Seesaw: modifyed parallel wire technique8 F guide2 OTW balloons /catheters2 wires slide parallel and are advanced in an alternating mannerSeesaw: modifyed parallel wireSeesaw WiringParallel Wire Method with Double Support CathetersmarkerSeesaw WiringP

31、arallel Wire MeSeesaw Wiring guide wires can exchange their roles as marker or penetratormarkerSeesaw Wiring guide wires can CTO at branch:Sesame open (Saito)And entry can still not be found: Sidebranch technique (Katoh)CTO at branch:Sesame open (SaSide Branch Technique Side Branch Technique Anchori

32、ng technique using OTW balloonAnchoring technique using OTW Subintimal Tracking and Reentry (STAR)techniqueSupportive 8Fr guideCreate or use existing dissection in proximal CTO (Miracle, Confianza, etc.)1.5mm balloon into trackWhisper/Pilot 50 with tight “J” tip/”umbrella tip”Advance with balloon su

33、pport, avoid spinning wire if possibleMay need pilot 150, 200 for proximalUse softest wire possible for distal (whisper)ReentrySubintimal Tracking and ReentrAnterograde Dissection and ReentryAnterograde Dissection and ReeSubintimal Tracking and Reentry (STAR)TipsStiffer polymer wire (“J”) proximally

34、 if needed but always softer distally“J-bend” media-to-media diameterRunoff vessels are keyVisualization of target/runoff vessels is keyReentry strategyDont lose true lumen distal branch, multiple wires if necessaryPTCA pre-stent conservative size, pressures 12 ATMBifurcation stenting only if absolu

35、tely necessarySB dissections may be OKDESConsider angiographic followupSubintimal Tracking and ReentrSubintimal Tracking and Reentry (STAR)Patient SelectionFailure with conventional wire strategies (parallel, see-saw)No retrograde opportunityRelatively healthy distal vessel beyond CTOMinimal importa

36、nt branches in shear/dissection zone (RCA, OM)Strong clinical indicationThis is final measure, not first measureSubintimal Tracking and ReentrInterventional techniques Improvement about CTO Miracale 1995Conquest 1999Parallel and seesaw 2000IVUS guide 2001STAR 2003SHOOTING and Fielder 2005 Tornus 200

37、5CART 2005Interventional techniques ImprRetrograde approachAnterograde failureBest septal collateral 7F shorter guide catheter 70-90cmACT300 secondsMicrocathter softer and hydrophilic wire Retrograde approachAnterograde慢性完全性閉塞的導(dǎo)絲技術(shù)介紹課件CTO Guide Wire Considerations(1)Start with softer guide wiresCons

38、ider hydrophilic for sub-total occlusionsConsider hydrophilic for heavy calciumOtherwise, start with soft, hydrophobic wiresAdvance to stiffer wires carefullyConsider parallel wire techniques if subintimalHydrophobic wires offer best tactile feel of lesionCTO Guide Wire Considerations(EntryUnfavorab

39、leFavorableStump; no entry point; wire will favor side-branchWell defined nipple into which wire can be directedEntryUnfavorableFavorableStump MIRACLEbros Family Confianza FamilyBetter torque performanceLess torque performanceLess penetration forceBetter penetration forceBetter crushing forceLess cr

40、ushing forceBetter tactile feelingLess tactile feelingCommon CTO wire characters(2) MIRACLEbros FamilyBetter tor MIRACLEbros Family Confianza Familyto advance in the hard CTO with tortuosity,to penetrate proximal or distal cap (parallel),to puncture from pseudo to true lumen (IVUS guide).to puncture

41、 from pseudo to true lumen.is more controllableshould be usedto penetrate proximal or distal cap,only when the near target is detected, Confianza Family should not be usedto seek the true channel or advance over a long distance,particularly in CTO with tortuosity.Common CTO wire characters(3) MIRACLEbros Familyto advanceSupport Catheters1.5mm balloonTransitILT support catheterSpectronetics Quick Cross St Judes Venture deflecting support catheterTo