PCI guidewires
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1) Guidewire technology has advanced significantly with a wide selection for different lesion characteristics and vessel anatomies. 2) Guidewires consist of a core material, taper, tip style, coils, and various coatings which determine properties like flexibility and trackability. 3) The choice of guidewire depends on factors like vessel anatomy, lesion morphology, and the intended procedure or device. Workhorse wires are preferred for simple lesions while more complex cases require dedicated wires.
PCI guidewires
- 1. Guidewires in 2017- an Update Mohamad Ashraf Ahmad, MD Lecturer of Cardiology – Assiut University
- 2. AGENDA • Historical background • Components of the guidewire • Specifications of the wires • Recent guidewire • Choice of guidewires • Workhorse wires • Bifurcation lesions • Tortuous artery • Thrombotic lesions • Dissections • CTO
- 3. Historical background Guidewire technology has since advanced significantly, with a wide selection for different lesion characteristics and vessel anatomies.
- 4. Structure of guidewires - Core material - Tip style - Core diameter - Covers and coils - Core taper - Coating
- 5. The Core of the wire • It is the inner part of the wire. • The proximal end is predominantly made of steel. • The shorter distal end is generally either stainless steel, nitinol or durasteel . • Core material determines properties such as tip load, flexibility, steerability, trackability, and support.
- 6. • The thickness of the core directly corresponds to the support of the wire; the thicker the core, the higher the support and the less the flexibility. • Core tapering • Long taper • Short taper
- 7. Core Tapering Gradual or long tapers produce a wire with less support but which tracks successfully . Abrupt or short tapers produce a wire which provides greater support but also greater tendency to prolapse.
- 8. Tip of the wire • Core to tip design: Good tactile feedback and tip control with a torque rate close to 1:1 • Shaping ribbon design: Good shape retention and a unique softness and flexibility of the tip, although at the cost of less tip torque control
- 9. • Taperd tip: • Conventional wires are typically 0.014 inches in outer diameter from the proximal end up to the distal tip. • In more dedicated wires tapering of the tip facilitates penetration.
- 10. • Coils (shape retention and proper tactile feedback • Polymer (plastic) cover gives excellent lubricity trackability with less tactile feed back. Coil and Cover
- 11. Coating of the wire • Hydrophilic coating: • Create a slippery ‘gel-like’ surface. • It makes the wire more lubricous and easier to advance. • Less tactile feedback. • Hydrophobic coating: • Repels water to create a ‘wax-like’ surface which enhances tactile feedback but decreases slipperiness and trackability • Hybrid coatings: • Combine hydrophobic tip coils for tactile feedback and tip control with hydrophilic intermediate coils for smooth device delivery..
- 13. Specifications of guidewires • The specifications of a guidewire can be described using the following terminology: • Torquability: The measured ability of a rotating element, like a shaft, to overcome turning resistance. The ultimate goal of achieving 1:1 steering. • Trackability, deliverability or crossing: The wire’s ability to follow the tip and to be advanced smoothly along the vessel, through stenoses or even occlusions.
- 14. • Tactile feedback: The kind of response the operator can detect regarding any resistance in torque or advancement occurring at the tip. • Tip load or tip stiffness: Tip load is a measure of the force needed to buckle the tip when forced against a standard surface. The tip load of available guidewires typically varies between the range of 0.5–15 g.
- 15. • Support: A measure of a guidewire’s resistance to a bending force. • A more supportive wire can aid in device delivery and vessel straightening, while a less supportive wire can aid in accessing through tortuous anatomy.
- 18. ASAHI SION First choice guide wire with a flexible shaft and full hydrophilic coating, recommended for tortuous vessels and side branches.
- 19. ASAHI SION BLUE Frontline guide wire with great tip flexibility and support for a safer procedure up to the stent delivery.
- 20. ASAHI SION BLACK Frontline guide wire with a polymer jacket designed to retain flexibility while crossing high resistance stenosis and vessels.
- 21. ASAHI fielder FC Fine control over challenging tortuous vessels and highly stenosed lesions. Polymer sleeve provides advanced slip performance with superior torque and support.
- 22. ASAHI fielder XT Is a polymer sleeve covered wire providing excellent lubricity and trackability in tortuous vessels. The tapered tip provides extreme precision for the treatment of complex lesions such as sub-total occlusions and long diffused lesions.
- 23. ASAHI Fielder XT-R Guide wire recommended for narrow channel tracking with its low profile, flexible tip, and high lubricity polymer coating.
- 24. ASAHI Fielder XT-A Guide wire with a higher tip load than Fielder XT-R, facilitating entry into the chronic occluded lesion.
- 28. ASAHI Gaia Family Guide wires with a high manoeuvrability in the chronic occluded lesion, and a tip designed to improve penetrability into the lesion while remaining flexible.
- 30. ASAHI Gaia third
- 33. ASAHI CONFIANZA PRO A tapered tip guide wire available in 9gf and 12gf Tip loads. For penetration of calcification and proximal or distal thick, fibrous caps. The distal tip is not coated to allow it to catch on the entry point of the lesion.
- 35. ASAHI RG3 For guide wire externalization only.
- 36. Which wire for which lesion? • It depends on: • Vessel anatomy (tortuous, Angulated, … • Lesion morphology (simple lesion, subtotal occlusion, CTO, • The device to be used (balloon, stent, IVUS, rotabalator,..) • Operators experience and preferences
- 37. Simple lesions (Workhorse wire) • Short, concentric stenoses in the presence of a traightforward anatomy. • Safe wire (atraumatic tip) • Favourable torquability and trackability. • BMW, Choice floppy, ASAHI soft,
- 38. Tortuous anatomy • In the case of severe tortuosity the emphasis needs to be placed on flexibility, lubricity and excellent trackability. • The best choice might be a wire with a polymer/hydrophilic cover. • Soft tip is more favourable, since the risk of vessel injury over multiple bends is increased with a stiffer tip. • Therefore our first choice for such anatomy would be the BMW, the IQ, the ChoICE Floppy, the Whisper MS or the Pilot 50.
- 39. Bifurcations • Jailed Wires; attention in jailing polymer covrerd wire due to risk of stripping the cover during retrieval.. • Recrossing the stent struts to enter a jailed branch needs a floppy and slippery wire with good torquability and trackability. • Choice for bifurcation can be BMW, the IQ, the ChoICE Floppy, Choice PT the Whisper MS, the Pilot 50, Whisper ES
- 40. Acute or recent thrombotic occlusions • BMW, IQ, or the ChoICE Floppy workhorse wires usually successful. • Hydrophilic wires with a higher tip load (Whisper MS or the Pilot 50) may slightly increase the risk of subintimal dissection, although their use may be favourable when occlusion occurs within a tight stenosis or tortuous coronary segment
- 41. Wires in coronary dissection • Usually floppy, coiled tip workhorse wire succeed bypass the dissection and navigate to the true lumen (BMW, IQ and choice floppy). • Avoid the polymer covered slippery wires because they tend to go through the sub- intimal plane.
- 42. Wires in CTO • Dedicated CTO guidewires. • Anterograde approach:
- 43. Sliding • Micro-channels • CTO < 6 month • STAR technique • Hydrophilic coated and polymer covered wires • Fielder, Fielder XT, Fielder FC • Whisper, Pilot 50, and Choice PT
- 44. Contolled drilling • CTO with discrete entry point after failure of initial attempt with soft (intermediated wire) • Stiff, hydrophobic non tapered wires, • Miracles / Miraclebros
- 45. Penetration • Blunt entry point • Heavy calcific or resistent lesions • Alternative to drilling as workhorse technique after failure of initial soft wire • Superstiff taperd wires: • Conquest /confianza (9 g, 12 g) • Cross it XT 400 • MircalesBros 12
- 46. Retrograde approach • Collateral crossing: • Soft polymer coated wires either tapered, such as Fielder XT-R, or non-tapered, such as Sion black wire or Whisper LS. • Attacking Among the most frequently used retrograde wires are Miraclebros 3, Gaia 1 and Gaia 2 over the closely positioned microcatheter. • Wire Externalizations: ASAHI RG3, Prowater Flex
- 47. Complication of guidewires • Dissection • Perforation • Wire fracture • Tip entrapment
- 48. Take home message • A lot of available guidewires with variable characters and specifications. • Improper choice of guidewire may not only prolong the procedure, but also compromise its success. • Operators therefore need to be aware of the most basic properties and technical background of guidewires, and be familiar (by hands and mind) with at least half a dozen of them.
Editor's Notes
- #4: The balloon and the guidewire were advanced as a single unit with limited manoeuvrability.
- #6: Steel has good torquability and less flexibility while Nitinol has more flexibility but less torquability
- #15: Wide difference range highlights the importance of choosing the proper device for the proper anatomy, and balancing safety with efficacy.
- #16: The thickness of the core material is the predominant source of support properties.