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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3764_Библиотеки_им_академика_М_И_Перельмана
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78 PART III Wires Technology
Figure 9.11 Sasuke.
OTW port. This system provides augmented support and higher penetration force due to the stability of the catheter over the workhorse wire and
enables use of less extreme secondary curves of the
CTO wire, as the angle of approach is more coaxial, and can help prevent eccentric cap penetration. Elimination of side load can restore the force
that would be lost due to wire buckling compared
with standard microcatheters.
(2) Side branch access. Once a lesion is crossed and
luminal wire position is secured, a DLMC can ensure
that a secondary wire advanced through the OTW port
to access side branches will follow the same luminal
path, avoiding sub-intimal or abluminal wiring. This is
of particular value for side branches beyond the distal
cap of CTOs, or when re-wiring side branches through
stents as part of bifurcation procedures.
(3) Drug delivery. Treatment of no reflow with medications targeted at the distal coronary bed can be performed through the OTW port, without the risk of
losing wire position.
(4) Antegrade wiring. In addition to the original
application of accessing proximal caps that are angulated with side branches at the origin, the Re-Cross
catheter (IMDS) has been specifically engineered to
facilitate AWE and ADR approaches.
Sasuke
The Sasuke dual lumen microcatheter (Figure 9.11) is
tapered, with a soft 4.0 mm radio-opaque tip which
makes it trackable, with a 38cm hydrophilic coating
and stainless-steel shaft which enhances deliverability.
The OTW exit port is set back 6.5 mm from the tip,
which is not truly directional, but rotation of the catheter is possible for closer alignment of the exit port.
NHancer Rx
The NHancer Rx (Figure 9.12) is also tapered and
hydrophilic, with a radiopaque atraumatic tip. Similarly,
the OTW exit port is set back 6.5 mm from the tip, and
deliverability is aided by a removable stylet in the OTW
port.
Figure 9.12 NHancer RX.
Figure 9.13 ReCross.
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CHAPTER 9 Microcatheters: Characteristics and Use 79
ReCross
The ReCross microcatheter (IMDS) (Figure 9.13) is a
new device which differs slightly in its construction
and application. There is no monorail and it is delivered OTW through the tip which connects to the
white hub at the back. There are 2 exit ports set back 8
mm (blue) and 12
mm (white) positioned at opposite
sides of the catheter, separated by 180 degrees. The
white hub therefore allows the wire to exit at the tip,
and through the side exit port 12
mm back from the
tip, whereas the blue hub wire only exits from the 8
mm side port. This unique design facilitates both
antegrade wiring and antegrade dissection re-entry
techniques. As an antegrade tool it is a deliverable MC
that allows parallel wiring whilst maintaining the
original wire position and facilitating rapid wire
exchange and can similarly be used for intraplaque
redirection. In dissection re-entry, the 2 juxtaposed
exit ports allow co-axial wire exit to direct at the true
lumen. In doing so, the redundant lumen can simultaneously facilitate STRAW.
Directional
Angled SuperCross
The Angled SuperCross microcatheters (Teleflex)
(Figure 9.14) are designed to overcome sharp angulation, useful for wiring side branches particularly in
the context of complex disease. Specific scenarios
include retroflexed circumflex, diagonal branches in
tortuous LAD segments, and retrograde approaches
to grafted vessels with significantly distorted anatomy
when the 90° and 120° catheters are most useful. A
platinum/tungsten radio-opaque coil at the tip enables good visibility and torque response. Once the vessel has been accessed it can be exchanged by balloon
trapping.
Venture Rx
The Venture Rx rapid exchange microcatheter
(Figure
9.15) has an adjustable tip capable of up to a
90° angle to aid wiring in tortuosity and side branch
access. An 8 mm platinum tip provides good visibility,
Figure 9.14 Angled SuperCross.
80 PART III Wires Technology
Figure 9.15 Venture RX.
and multi-layered shaft construction enables good
torque control and kink resistance. Manipulation of
the tip deflection knob and torque handle at the proximal end allows precise angle adjustment according to
the task.
Acknowledgments
With thanks to Optima Education and Vascular
Perspectives for reference and illustration support. A
special thank you to Professor James Spratt, Dr Colm
Hanratty, Dr Simon J Walsh, Dr Simon Wilson who
are mentors and authors of the antegrade iBook which
I have learned from and use still on a regular basis.
IV
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PART IV
Wires Technique
10
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CHAPTER 10
CTO Wires: Engineering 101 and
Principles of Wire Manipulation
Rahul Kurup1 & Luiz Fernando Ybarra2,*
1
South West Sydney Local Health District (Campbelltown and Liverpool Hospitals) and Sydney Medical
School University of Sydney, NSW, Australia
2
London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London,
ON, Canada
* Corresponding author
Wire engineering 101
There have been significant technological advances in
the equipment used for percutaneous coronary intervention (PCI), and this is particularly evident in the current
generation of coronary guidewires. Understanding wire
technology and the construction of coronary guidewires
allows for better usage of the wire and increased technical
success rates. This is particularly important given that the
predominant mode of procedural failure in chronic total
occlusion (CTO) PCI using the contemporary “hybrid”
approach has been the inability to cross the lesion with a
guidewire [1]. A lack of understanding of the properties
and utility of wires available can also lead to increased
complications and prolonged procedural times.
Broadly speaking, the components of a coronary
guidewire (Figure 10.1) include shaft/body, transition
segment, and tip.
The wire shaft is arguably the least critical component
of the guidewire but plays a role in transmitting operator
hand movements and overall wire utility. The core, which
is attached to the distal end of the shaft and extends to the
tip of the guidewire, is often the stiffest part of the wire
that gives stability, support, and steerability. Most cores of
contemporary guidewires are made from stainless steel,
nitinol (nickel-titanium alloy), or a combination of the
two (i.e., stainless steel body with Nitinol distal tip seen in
the Runthrough guidewire from Terumo). Nitinol,
known for being a “memory metal” due to its good shape
retention, is more durable, flexible, and kink resistant
compared to stainless steel. Stainless steel, however, has
greater torque transmission with better support and
push. Another important parameter of the core that
affects the performance of guidewires is the core diam-
eter. A larger diameter core improves support and torque
transmission whereas smaller diameter cores are more
trackable.
The tip of the guidewire is often where most variation between wires exist and therefore plays the largest
role in determining overall performance and clinical
utility. The distal tip is covered with radiopaque
spring-coils (typically platinum) to allow fluoroscopic
visualization. Variations in the tip construction can
include the tip core style, tip core taper, spring-coils,
coatings, and covers. The clinical implications of these
variations are shown in Table 10.1.
Variations in overall guidewire construction can also
influence wire characteristics such as shaft support, tip
stiffness, torque transmission, wire lubricity, and trackability. Increased wire shaft support, which can be
quantitatively measured, leads to the increased ability
to deliver devices such as balloons and stents over the
wire. Highly supportive wires, such as the Grandslam,
Wiggle, and Ironman wires, can facilitate device
delivery through tortuous arterial anatomy.
Tip stiffness is defined as the load in grams (gramforce), measured using an electronic scale, needed to
buckle the tip of the guidewire to a fixed length
(Figure 10.2). As each company has its own specific
measurement methodology, the advertised tip load
may not be exactly comparable between wires of different companies. Stiffer wires can penetrate through
caps but have an increased risk of exiting the vessel
architecture resulting which can result in vessel dissection, false lumen creation, and perforation.
Newer technology has also improved wire torque
transmission which is the ease and efficiency of rotational force transmission applied by the operator at the
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
83
84 PART IV Wires Technique
Figure 10.1 Components of a coronary guidewire.
Table 10.1 Variation in distal tip components and its clinical implications.
Component Variation Clinical implication
Tip Type 2-piece core with shaping
ribbon (wire core does not
extend right to the tip)
1 piece core (core-to-tip) • Increased tip force transmission
Tip Core Taper Longer taper • Increased steering/trackability
Short taper • Easier to knuckle
Coatings Hydrophilic • Increased lubricity and trackability
Hydrophobic • Greater tactile feedback
Covers Polymer (over coils vs over
core)
• Increased shaping ability
• Easy to prolapse
• Increased safety due to softer tip
• Greater tactile feedback
• Less supportive
• Increased push force transmission
• Increased support
• Less tactile feedback
• Needs to be activated by water
• Less trackable compared to hydrophilic coatings
• Increased lubricity and improved vessel tracking
(useful for negotiating tortuous lesions and finding
microchannels in total occlusions)
Figure 10.2 Measurement of guidewire tip stiffness in
gram-force (gf). Image reproduced from Asahi Intecc
website.
proximal end of the guidewire to the distal end of the
guidewire (Figure 10.3). For instance, the Asahi Intecc
company, which has been monumental in guidewire
technology advancement, has incorporated novel designs
into their contemporary guidewires. The Sion TECC
technology, which involves the addition of Asahi’s proprietary ACT ONE rope coil over the twist and stainless
steel core wire (Figure 10.4), facilitates more efficient
torque transmission to the distal guidewire tip. Another
example of improved guidewire design is the Inner Coil
Technology (ICT) from Boston Scientific which involves
the addition of a stainless steel inner coil to the distal tip
of the stainless steel core (Figure 10.5). This improves
wire torqueability, shape retention and durability.
The addition of coatings and polymer covers over
guidewires influence the lubricity and trackability,
which is defined as how easily a wire navigates the coronary artery, particularly tortuous vessels, and very tight
occlusions. The coatings applied over the guidewire can
CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 85
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Figure 10.3 Torque Transmission. Image reproduced from [2] Vascular Perspectives Ltd.
Figure 10.4 Asahi ACT ONE wire technology. Image modified and reproduced from Asahi Intecc website.
Figure 10.5 Inner Coil Technology (ICT) wire technology.
Image provided courtesy of Boston Scientific. © 2022
Boston Scientific Corporation or its affiliates. All rights
reserved.
either be hydrophilic or hydrophobic. Hydrophilic
coatings (e.g., polyethylene oxide or polyvinyl pyrrolidone) require water to become activated and become
slippery with extremely low friction. On the other
hand, hydrophobic coatings (i.e., polytetrafluoroethylene (PTFE) or silicone) are inherently slippery and do
not require water for activation. In addition to guidewire tips, many wire shafts also are coated with silicone
or PTFE to improve movement within catheters.
Polymer covers, which are generally variants of polyurethane, can be added on top of hydrophilic coatings to
further enhance wire lubricity. Hydrophilic, polymerjacketed wires are often preferred to navigate subtotal
occlusions, highly tortuous vessels, or difficult to access
side branches. The trade-off between increasing lubricity
of a wire is decreased tactile feedback (Figure 10.6) which
Figure 10.6 Guidewire
lubricity vs tactile
feedback.
86 PART IV Wires Technique
is the operator’s ability to feel the interaction between the
wire and the vessel architecture. Therefore, hydrophilic,
polymer-jacketed wires can more easily enter the subintimal space and cause dissections and perforations.
In addition, dedicated wires used for specific case scenarios (i.e., externalization), are also needed.
“Workhorse” guidewires, which are used in most
PCI cases, refer to low tip load guidewires that
have a focus on safety. Some of the limitations of
CTO guidewires
There is a plethora of specialty coronary wires currently available for commercial use and this offers a
range of options for CTO operators (Table 10.2).
Although it would be a luxury to have every wire
available in the lab, the practical reality is that this is
limited by cost, redundant wire design, and wire
familiarity. Therefore, most CTO operators choose to
work with a subset of wires that they are familiar with.
Table 10.2 Selected Coronary Guidewires Used in CTO Interventions.
Name Manufacturer Core
material
Sion Blue Asahi Intecc Stainless
steel
Minamo Asahi Intecc Stainless
steel
Samurai Boston
Scientific
Hi-Torque
BMW
Universal II
Runthrough
NS Extra
Floppy
Sion Asahi Intecc Stainless
Prowater Asahi Intecc Stainless
Hi-Torque
Turntrac
Specter Teleflex Nitinol/
Marvel Boston
Runthrough
NS floppy
Samurai RC Boston
Abbott Nitinol 0.6 Spring coil
Terumo Nitinol/
Abbott Nitinol 0.8 Spring coil
Scientific
Terumo Nitinol/
Scientific
Stainless
steel
Stainless
steel
steel
steel
Stainless
steel
Stainless
Steel
Stainless
steel
Stainless
Steel
Tip
Tip style Tip coating Tip
Load
(g)
0.5 Spring coil
Core-to-tip
ACT ONE cable
0.5 Spring coil
Core-to-tip
ACT ONE cable
0.5 Spring coil over
inner coil (ICT)
Core-to-tip
Shaping ribbon
0.6 Spring coil
Core-to-tip
0.7 Spring coil
Core-to-tip
ACT ONE cable
0.8 Spring coil
Core-to-tip
Core-to-tip
0.9 Spring coil
Shaping ribbon
0.9 Spring coil
Core-to-tip
1.0 Spring coil
Core-to-tip
1.2 Spring coil over
inner coil (ICT)
Core-to-tip
“workhorse” guidewires that affect its utility in
CTO PCI include insufficient tip stiffness, lubricity
and push that are often needed to traverse CTO
caps which can be fibrotic and calcified. A major
factor for the increased success rates seen in CTO
PCI is improved wire technology resulting in
stiffer and more supportive wires with greater
torque response and wires with modified coatings
and tapered tips.
“Workhorse”
Characteristics
Radiopacity
Hybrid 3cm Hydrophobic silicone
coating from tip to
1.5cm, then
hydrophilic coating.
Dark color shaft
Hybrid 3cm Hydrophilic with
hydrophobic silicone
distal tip
Hydrophilic 4cm ICT – Inner Coil
Technology
Hydrophilic 3cm
Hybrid 3cm Hydrophilic coat with
silicone distal tip
Hydrophilic 3cm Flexible shaft for
increased trackability
Hydrophilic 3cm
Hybrid 3cm “Responsease”
Parabolic Core Grind
Hydrophilic 3cm
Hydrophilic 3cm
Hybrid 3cm Hydrophilic coat with
silicone distal tip
Hydrophilic 4cm Increased flexibility vs
Samurai
CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 87
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Table 10.2
(Continued)
Very low tip load
Suoh 03 Asahi Intecc Stainless steel 0.3 Spring coil
Core-to-tip
ACT ONE cable
Polymer Coated, Non-tapered
Name Manufacturer Core
material
Whisper LS/
MS/ES
Fielder FC Asahi Stainless
Sion Black Asahi Stainless
Pilot 50 Abbott Stainless
Choice PT Boston
PT2
Intermediate
Mongo/
Gladius MG
14
Pilot 200 Abbott Stainless
Raider Teleflex Stainless
Abbott Stainless
Steel
steel
steel
Steel
Stainless
Scientific
Boston
Scientific
Asahi Intecc Stainless
Steel
Nitinol 2.9 Spring coil Hydrophilic
steel
steel
Steel
Tip Load
(g)
1.0/1.0/1.3 Spring coil
0.8 Core-to-tip Hydrophilic
0.8 Spring coil
1.3 Spring coil
2.1 Core-to-tip Hydrophilic
3.0 Spring coil
3.9 Spring coil
4.0 Spring coil
Tip style Tip coating Tip
Core-to-tip
Core-to-tip
ACT ONE cable
Core-to-tip
Core-to-tip
ACT ONE cable
Core-to-tip
Core-to-tip
Hydrophilic 3cm Retrograde wiring
High shaft
flexibility
Characteristics
Radiopacity
Hydrophilic
over polymer
over polymer
Hydrophilic
over polymer
Hydrophilic
over polymer
over polymer
over polymer
Hydrophilic
over polymer
Hydrophilic
over polymer
Hydrophilic
over polymer
3cm
3cm
3cm
3cm
35cm No coils
2cm
3cm Short ACT
ONE- Creates
smaller
knuckle
3cm
10cm
Polymer Coated, tapered tip
Name Manufacturer Core
material
Fielder XT -R Asahi Intecc Stainless
Steel
Bandit Teleflex Stainless
Steel
Fielder XT Asahi Intecc Stainless
Steel
Fielder XT-A Asahi Intecc Stainless
Steel
Tip Load
(g)
0.6 Tapered
0.8 Tapered
0.8 Tapered
1.0 Tapered
Tip style Tip coating Tip
(0.010”)
Spring coil
Core-to-tip
ACT ONE cable
(0.008”)
Core-to-tip
Spring coil
(0.009”)
Spring coil
Core-to-tip
(0.010”)
Spring coil
Core-to-tip
ACT ONE cable
Hydrophilic
over polymer
Hydrophilic
over polymer
Hydrophilic
over polymer
Hydrophilic
over polymer
Characteristics
Radiopacity
16cm
10cm
16cm
16cm
(Continued)
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