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88 PART IV Wires Technique

Table 10.2 (Continued)

Name Manufacturer Core

material

Fighter Boston Scientific Stainless

Steel

Progress 140T/200T

Name Manufacturer Core

Gaia 1st/2nd/3rd

Gaia Next 1/2/3

Ultimatebros 3Asahi Intecc Stainless

Judo 3/6 Boston

MiracleBros 3/6/12

Confianza Pro /12 Gaia Next 4 Asahi Intecc Stainless

Hornet 10/14 Boston

Infiltrac Abbott Stainless

Infiltrac Plus Abbott Stainless

Abbott Stainless

Steel

“Intermediate” to “Stiff” Non-Polymer Coated

material

Asahi Intecc Stainless

steel

Asahi Intecc Stainless

steel

Stainless

Scientific

Asahi Intecc Stainless

Scientific

steel

Stainless steel

steel

Tip Load (g)

1.5 Tapered

15.5/13.5 Tapered

Tip Load (g)

1.7/3.5/4.5 Tapered

2/4/6 Tapered

3 Non-tapered Hydrophilic

3/6 Tapered (0.008”)

3/6/12 Non-tapered

9/12 Tapered (0.009”) Hydrophilic 20cm

10 Tapered (0.013”) Hydrophilic 15cm Micro cone tip;

10/14 Tapered (0.008”)

10.8 Tapered (0.009”)

13.9 Tapered (0.009”)

Tip style Tip coating Tip

Radiopacity

Hydrophilic (0.009”) Core-to-tip Spring coil

(0.0105”/0.009”) Spring coil Core-to-tip

Tip style Tip coating Tip

(0.010/0.011/0.012”)

(0.011/0.012/0.012”)

Core-to-tip Spring coil

Core-to-tip Spring Coil

Core-to-tip Spring coil

over polymer

Hydrophilic

over polymer

Hydrophilic 15cm Micro cone tip;

Hydrophilic with uncoated tip

with uncoated tip Hydrophilic 3.5cm Preformed

Hydrophobic 11cm Tapers close to

Hydrophilic 3.5cm

Hydrophilic 3cm Preformed

3.5cm

3cm

Radiopacity

15cm Micro cone tip;

11cm

Characteristics

ACT ONE tip cable; Preformed 1mm micro-J tip,

ACT One cable and XTRAND coil at tip;

micro-J tip

the tip (less prone to prolapse; good support)

XTRAND tip coil; Preformed 1mm micro-J tip

micro-J tip (25° angle, 1mm from tip)

CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 89

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Table 10.2

(Continued)

Name Manufacturer Core

material

Warrior Teleflex Stainless

steel

Astato XS 20/40

Name Manufacturer Core

Hi-Torque Wiggle

Grandslam Asahi Intecc Stainless

Hi-Torque Ironman

Mailman Boston

Asahi Intecc Stainless

steel

material

Abbott Stainless

Steel

steel

Abbott Stainless

Steel

Stainless

Scientific

Steel

Tip Load (g)

14 Tapered (0.009”)

20/40 Tapered (0.008”)

Tip Load (g)

0.5 Shaping

0.7 Spring

0.8 Spring

Tip style Tip coating Tip

Core-to-tip Spring Coil

Support

Tip style Tip coating Tip Radiopacity Characteristics

Hydrophobic 2 or 30cm Has pre-formed ribbon Spring coil

Hydrophobic 4cm coil Core-totip

Hydrophobic 3cm coil Core-totip

Hydrophilic coil

with distal

3cm

uncovered

Radiopacity

Hydrophilic 2.5cm

Hydrophilic with uncoated tip

17cm 0.014”

3cm

Characteristics

Peripheral guidewire

distal “wave” deflections in wire

Name Manufacturer Core

material

RotaWire Drive Floppy RotaWire Drive Extra Support ViperWire Advance ViperWire Advance with Flex Tip

Name Manufacturer Core

RG3 Asahi Intecc Stainless

Boston Scientific Stainless

steel

Boston Scientific Stainless

steel

CSI Stainless

steel

CSI Nitinol 0.014”, 1.0 g tip

Tip Load

material

steel

(g)

3 Spring

Atherectomy

Tip style Body

diameter

2.2cm, 0.014” spring tip

2.8cm, 0.014” spring tip

0.014”, 1.4

Stainless steel support coil

Externalization

Tip style Tip coating Tip Radiopacity Characteristics

coil Core-totip

g tip 0.012” 325cm length

Hydrophilic 3cm 330cm length

0.009” 330cm length

0.012” 325cm length

Characteristics

Flexible

Stiff

Increased flexibility

0.010” shaft diameter Proximal hydrophobic silicone coating

(Continued)

90 PART IV Wires Technique

Table 10.2 (Continued)

Name Manufacturer Core

material

R350 Teleflex Nitinol 3 Spring

Tip Load (g)

Tip style Tip coating Tip Radiopacity Characteristics

coil Core-totip

CTO guidewires classified by clinical case use

Accessing target of interest

It is recommended to get to target of interest (e.g., proximal cap of a CTO or a suitable septal collateral) using a microcatheter and a soft, “workhorse” guidewire in order to minimize vascular injury. Once at the target site, if needed, the guidewire can be swapped out for a different guidewire based on the treatment strategy. Commonly used workhorse guidewires include the Sion Blue (Figure 10.7), Hi-Torque BMW Universal II (Figure 10.8) and Samurai (Figure 10.9).

Hydrophilic 5cm 350cm length

0.013” shaft diameter Higher kink resistance

Navigating microchannels

Pathological examination of CTO lesions have demonstrated the presence of small vascular microchannels within the plaque which are not appreciable on angiography [3]. These microchannels are often at the border between the loose and dense fibrous tissues. Navigating microchannels within a CTO requires a guidewire with high lubricity, which is often conferred by the addition hydrophilic, polymer coatings over the wire. This includes tapered wires from Fielder XT series (Figure 10.10) from Asahi, the Fighter (Figure 10.11) from Boston Scientific and the Bandit (Figure 10.12) from Teleflex.

Figure 10.7 Asahi SION blue guidewire. Reproduced from Vascular Perspectives website [2].

Figure 10.8 BMW Universal II coronary guidewire. Adapted from Abbott website.

CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 91

SAMURAI Guidewire

Hydrophilic Coating

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Coil Length (24 cm) / Hydrophilic Coating

Radi opaque (4 cm )

Moderated Hydrophilic

1 cm

Stainless Steel

PTFE Coating

Core

Figure 10.10 Fielder XT series of coronary guidewires. Reproduced from Vascular Perspectives website [2].

92 PART IV Wires Technique

Figure 10.12 Bandit Coronary Guidewire. Adapted from Teleflex® website.

Cap penetration

In CTO lesions that are highly fibrotic or calcified, higher gram tip guidewires are often needed for direct puncture into the lesion. The CTO ARC consensus document have classified high gram tip load guidewires as having a tip stiffness of > 6grams [4]. In addition to tip load, the penetration power of a wire can be enhanced by the addition of a polymer coating and instilling a tapered tip to reduce its surface area.

The antegrade wiring strategy involves sequentially moving through guidewires of increasing tip stiffness to puncture the proximal cap of a CTO. Once the proximal cap is penetrated and the microcatheter advanced, the stiff tip guidewire may be switched to

another guidewire according to the strategy being used (intraplaque navigation or knuckling/dissection and re-entry).

Higher tip load wires, which are also often needed for navigating highly calcified plaques, include the Confianza Pro (9 or 12 gram tip load) from Asahi Intecc, Hornet (10 or 14 gram tip load) from Boston Scientific and Inflitrac series (Figure 10.13) from Abbott Vascular. The Infiltrac (11 gram tip load) and Infiltrac Plus (14 gram tip load) wires come with a preformed 25° angle micro-J tip located 1 mm from the tip which enhances tip steering and navigation within CTO lesions. Generally, higher tip load wires should only be used when there is no cap ambiguity

1 mm from tip

at25°

Figure 10.13 Confianza Pro 12, Hornet 14 and Infiltrac coronary guidewires. Reproduced from Vascular Perspectives [2] and Abbott Vascular websites. Hornet 14 image provided courtesy of Boston Scientific. © 2022 Boston Scientific Corporation or its affiliates. All rights reserved.

CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 93

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and the vessel course is known as there is a higher risk of exiting the vessel wall with these wires.

Intraplaque navigation

A widely used wire for intraplaque navigation is the Gaia series from Asahi Intecc. The initial Gaia family

10.14) has various tip diameters at increasing

(Figure tip loads and utilizes the composite tip core with the ACT ONE tip cable and SION TECC technology to improve torque transmission and tip flexibility within the CTO lesion. The ACT ONE cable also suppresses whip motion of the wire tip. The next generation of wires are the Gaia Next family (Figure 10.15), which in addition to the ACT ONE, has a flexible, micro-cone tip for increased

directional control within the body of the CTO as well as the novel XTRAND tip coil for increased anti-trapping power within lesions. Another commonly used guidewire for intraplaque navigation is the Judo

series (Figure

10.16) from Boston Scientific. This series of tapered wires consist of Judo 1, 3, and 6 with varying tip loads of 1,3, and 6

grams respectively. The Judo series utilizes Micro EMT technology which provides a matching long taper (6

cm) of the core and coil from 0.014” to

0.008” allowing for increased flexibility of the distal portion and improved intraplaque maneuverability.

Navigating retrograde collaterals

The retrograde approach is another therapeutic strategy in CTO PCI and potential retrograde conduits include bypass graft conduits, septal collaterals and epicardial collaterals. Given the friable and highly tortuous nature of particularly the septal and epicardial collaterals, the wires used here need to be highly trackable and flexible with low tip loads to navigate the vessels. Commonly used wires for retrograde septal wiring include the Suoh 03, Sion and Sion Black

Figure 10.14 Asahi Gaia coronary guidewire. Reproduced from Vascular Perspectives website [2].

94 PART IV Wires Technique

Figure 10.15 Asahi Gaia Next coronary guidewire. Adapted from Asahi Intecc website.

wires (Figure 10.17). The Suoh 03 is also used frequently in retrograde epicardial wiring. The Suoh 03 has a very low tip load of 0.3grams hence reducing the risk of potential trauma to the gentle epicardial vessels. The downside is that it is extremely easy to prolapse and deform, increasing the risk of perforation and leading to multiple replacements of the wire during the case.

Fielder XT and Gladius MG tend to create smaller knuckles, compared with the Pilot 200, which forms larger knuckles. Smaller knuckles can potentially enter side branches, whereas larger ones may create larger dissection planes, facilitating extraplaque hematoma formation. Generally, knuckling polymer jacketed wires are the preferred strategy for navigating CTOs where the course of the vessel is unknown as the risk of exiting the vessel with a knuckled wire is low. Occasionally, stiffer guidewires

Guidewires for dissecting and knuckling into extraplaque space (Dissection and Re-entry)

In long CTO segments or where the CTO cap cannot be successfully punctured and the vessel course is not known, Dissection and Re-entry (DR) is a useful technique that can be performed in both the antegrade (ADR) or retrograde (RDR) directions. Dissections can be performed with devices or wires. The safest

are required to re-enter into the true lumen from the extraplaque space. Examples of these guidewires include the tapered-tip Confianza (12 gram tip load) or the Hornet 14, or the specialized re-entry Stingray guidewire, which has a pre-shaped 12 gram tip load with a distal probe and is frequently used with the Stingray LP dissection re-entry device (Boston Scientific).

form of wire-based dissection is using a knuckled hydrophilic, polymer jacketed wire in the extraplaque space to navigate around the CTO (Figure 10.18).

Commonly used wires for dissecting include the Fielder XT, Gladius MG (also known as the Mongo wire in the US) and Pilot 200 (Figure 10.19). The

Externalization guidewires

Once a CTO has been successfully crossed using the retrograde approach, the next step is to gain antegrade access of the segment distal to the CTO. The most common way of achieving that is by externalizing the

CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 95

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Figure 10.17 Commonly used coronary guidewires for retrograde conduit access. Reproduced from Vascular Perspectives website [2].

ever dedicated externalization guidewires have shown to be more effective and reliable. The RG3 and R350 guidewires (Figure 10.20) have a shaft diameter of 0.010” and

0.013”, respectively, and a hydrophilic coating, making them ideal for externalization. The R350 guidewire has a nitinol core and is more kink resistant. RG3’s stainless

Figure 10.18 Antegrade dissection re-entry with balloon inflation in the extraplaque space.

retrograde guidewire through the antegrade guiding catheter. In order to facilitate externalization, these specialty guidewires need to be longer in length (i.e. >300cm) and have low friction, which is obtained with a smaller diameter size and higher lubricity. Previously, atherectomy guidewires such as the ViperWire and RotaWire were used as externalization guidewires, how-

steel core makes it more pushable and supportive.

Principles of wire manipulation

The first step prior to wiring the lesion is to select the appropriate angiographic views to use as reference images. It is important that the lesion is not foreshortened and the proximal vessel leading to the lesion is well laid out. It is essential for the operator to have a mental roadmap of CTO entry point,

96 PART IV Wires Technique

Figure 10.19 Gladius MG and Pilot 200 coronary guidewires. Adapted and reproduced from Vascular Perspectives [2] and Abbott vascular websites.

Figure 10.20 RG3 and R350 Externalization Guidewires. Adapted and reproduced from Vascular Perspectives [2] and Teleflex® websites.

body and exit point as well as the distal true lumen position based on angiographic assessment using different angles and bilateral injections.

Shaping the guidewire

In complete occlusions, the main strategy is to try to engage the lesion in the middle. This is facilitated by

CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 97

Tip Stiffness (gfs)

Length extending from the Tip of a Microcatheter

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creating a “CTO bend,” which is a 45° primary bend

mm proximal to the tip of the guidewire (Figure

10.21, Panel a). This is often the small bend possible due to length of soldering in most guidewires. A secondary bend can then be used more proximally if there is vessel tortuosity, or the contact point cannot be reached with the primary bend. The secondary bend is normally sized to the size of the vessel itself (Figure 10.21, Panel b).

Tactile feedback from the guidewire

Tactile feedback is very important in CTO PCI to ascertain the position of the wire within the lesion. Therefore, operators need to familiarize themselves with the feel of coronary guidewires within coronary arteries and different types of coronary plaques. Engagement of the proximal cap is often described as a “dimple” sensation. As previously shown in Figure 10.6, it is important to note that tactile feedback is diminished with polymer coated guidewires and when the guidewire is in the subintimal space. Operators need to watch the tip of the guidewire closely to check for tip buckling, which is a hint of non-true lumen position of the guidewire. If there is no resistance to wire advancement, the wire tip could either be in the subintimal space, in the pericardial space, or within the true lumen. In this instance, wire position should be confirmed using dual angiography. It is imperative to not manipulate the subintimal wire too much as this can extend the extraplaque space leading to larger hematoma formation.

Modulating guidewire tip stiffness

The tip stiffness of a guidewire can be modulated by using over-the-wire (OTW) systems such as microcatheters or OTW balloons. The length of the guidewire tip from the OTW system can be varied to increase the stiffness of the guidewire (Figure 10.22). A shorter length will lead to increased tip stiffness; therefore, this can be adjusted based on the lesion. Microcatheters are generally more flexible compared to OTW balloons and therefore makes in preferable in CTO interventions. In addition to this, there are

Figure 10.21 Shaping the tip of the coronary guidewire with an isolated primary bend (Panel a) or with both a primary and secondary bend (Panel b).

Figure 10.22 Change in guidewire tip stiffness at various lengths from the microcatheter tip. Reproduced with permission from Waksman and Saito. Chronic total occlusions: a guide to revascularization. Wiley-Blackwell;

2013.

Extrapolated by using the 2nd order fitness function.

Conquest- Pro 12 Miracle3

BMW

2.4

2 4

12 14 16 18 20 22

microcatheters with specific properties such as double braided shafts and torque ability which facilitate the crossing of CTO lesions.

Other strategies to increase guidewire tip stiffness and penetration power into a CTO lesion include the use of a guide extension catheter, deep seating the guide, using a more supportive guide, using an anchor balloon in a side branch proximal to the CTO or inflating an anchor balloon to trap the OTW system within the vessel to increase the push vector of the guidewire into the proximal cap.

Guidewire manipulation techniques

The main movements used in guidewire manipulation are rotational and advancement-retraction movements. Both these movements can be performed using either a one-handed or two-handed technique. In the two-handed technique, the left hand is reserved for “push-pull” movements to either advance or retract the guidewire whereas the right hand is use for rotating the tip of guidewire to allow interrogation of a different tissue plane if resistance is encountered at the wire tip. In the one-handed technique, the right hand usually does both the advancement-retraction and rotational movements. This manipulation is more akin to a controlled drilling motion where the wire tip is used to dissect the tissue plane within the lesion. Operators can adjust their technique depending on the clinical situation and may elect to use both the one-handed and two-handed manipulation techniques in some cases.

Wires can be manipulated using only the fingers or with torque devices. Finger manipulation provides higher tactile feedback and allows to drill the wire faster. Torque devices on the other hand, are useful adjuncts that provide more torque control and precision.

The most common guidewire manipulation techniques are penetration, drilling,

controlled-torquing,

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