慢性完全性闭塞导丝技术应用总体介绍

1、慢性完全性闭塞导丝技术应用总体介绍ContentsDefinitionPathologyAngiography imagingPCI technical challenge guidewire technology interventional devices revascularization technologyDefinition of CTOChronic total occlusions are defined as occlusions greater than 3(1) month old with angiographic TIMI 0 or TIMI 1 flowThe Sp

2、ectrum of Lumen Morphology in CTO: Clinical ChallengesNecrotic coreProteoglycan-richCalcificationLarge recanalizationchannelsInflammationSmall recanalizationchannelsFibrotic plq:NegativeremodellingChronic Total OcclusionsWhats Blocking up the Lumen?1. Dense Fibrotic Tissue: COLLAGEN!2. Calcification

3、NCVIntraluminal CollagenExtracellular Matrix: Collagen, CalciumIncreased fibrocalcific plaques with ageSrivatsa et al, J Am Coll Cardiol 1997:29:955-63 Intraluminal CalcificationVariables related successAge of OcclusionEntryLengthTortuousityCalciumCollateralsDistal Vessel SizeIn-stent occlusiondevic

4、esAnatomic Descriptorsof Procedural SuccessAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire U

5、se AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesHallmarks of a CTO Guidewire Tip styles - core-to-tip designs; sometimes tapered Coils and covers - some favor increased radiopacity; jointless coils for improved torque response; polymer covers for selected applications Core tapers and materi

6、als - shorter tapers for improved torque response; generally stainless steel Core diameters - larger for increased support and torque response Coatings - hydrophilic for tracking (body) and hydrophobic for torque response (body and tip)ASAHI MIRACLEBROS 3ASAHI MIRACLEBROS 4.5ASAHI MIRACLEBROS 6ASAHI

7、 MIRACLEBROS 12ASAHI MIRACLEBROS Family Straight Tip Guide WiresCharacteristics:Core-to-tip design (unique wire drawing process)Non-tapered tip11 cm of radiopacitySmooth tractability & delivery with Joint-less distal coil technologyHydrophobic coatingIncreasing tip loads 3 -12 gmExcellent tip shape

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

9、NFIANZA Pro “8-20” Tapered Tip Guide WireCharacteristics:Stiffest tip - 20 gmTapered tip - .00820 cm radiopacitiy Joint-less technologyHybrid coating Greatest penetrating force The combination of a polymer cover and hydrophilic coating provides outstanding lubricity. Tip coils beneath the polymer he

10、lp facilitate tip shaping.HI-TORQUE PILOTTM Family of Guide wireCordis SHINOBI & SHINOBI PlusCTO GuidewiresUnique flattened tip designed to cross subtotal occlusionsFlattened radiopaque coils.0070” Corewire SupportSHINOBI.0100” Corewire SupportSHINOBI Plus1. Coronary CTOs have many typesof lesion mo

11、rphologies.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.Wire selection and wire handlingGuide Wire Selecti

12、onMost important considerationsTorque responseTip feel (tactile response)Tip shape curve formationHydrophobic vs. Hydrophilic WiresHydrophobic wiresProvide better tactile response to operator Provide operator improved tactile response to better navigate micro-channelsTo get into the “dimple” and use

13、 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 spacesHydrophilic wires tend to follow the path of least resistance and generally offer less tip controlSimplif

14、yed sequence of wiresEasy case ( big vessel, straight )Crossit 100Confianza proDifficult case (calcifyed, tortuous, smaller) Miracle 3gProx. Tortuosity: lubricious wiresMiracle 4.5-12 gConfianza wiresParallel wire: Confianza 6g 12gWhy so difficult to cross it ?Sub-Intimal PathWire technique for loca

15、ting another channel Tip Shape Is KeyWire tip for CTOCTOStenosisTip 1 mmTip 2-3mmAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesGuidewire Operator TechniquesPENETRATIONDRILLING(controlled) S

16、LIDINGDRILLING(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 stiffnessPremium on tactile responsesP

17、ENETRATIONGuidewire 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 even heavily calcified entry cap (9-12 gms and tapered)Reduced tac

18、tile responsivenessAllways steer towards inner curve ! Twist gently , push and pull ! Dont inject dye via OTW-catheter !In curved vessels, the optimal site for penetrating the fibrous cap is towards the myocardium (mural ) No !Penetration vs. Controlled Drilling DrillingTechniques of CTO Guidewire M

19、anipulationTechniques of CTO Guidewire ManipulationPenetration vs. Controlled DrillingDirectional control of the tip is more precise in “Penetration”Advancement of the tip is easier in “Controlled Drilling”SLIDINGGuidewire Operator Techniques Longer and shallower tip shapes and no secondary bendsSim

20、ultaneous tip rotation and probingAlmost no tactile responseTakes advantage of reduced guidewire surface friction requires polymer cover Anatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesDRILLI

21、NG(controlled)CTO Guidewire Categories Abbott CROSS-IT wires (100, 200,and 300)Asahi-Abbott MIRACLE Bros wiresMedtronic PERSUADER wires (3 and 6 gm)PENETRATIONCTO Guidewire Categories Abbott CROSS-IT 400 wireAsahi-Abbott CONFIENZA wires (regular and PRO) - 9 and 12 gmMedtronic PERSUADER wire - 9 gmS

22、LIDINGCTO Guidewire Categories Abbott PILOT and Whisper wiresBSC PT wiresCordis SHINOBI wiresAsahi Fielder wiresAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesDRILLING(controlled)Lesion-Spec

23、ific CTO Approaches Most CTOs with discrete entry point;after initial attempt with soft (intermediate) wires“Workhorse” techniquePENETRATIONLesion-Specific CTO Approaches Blunt entry pointHeavily calcified or resistant lesionsAlternative to “drilling” as workhorse technique after initial soft wire f

24、ailure SLIDINGLesion-Specific CTO Approaches Microchannels present or sub-total occlusion (residual channel)ISR total occlusionsSome calcified and angulated lesions STAR technique (subintimal reentry)Recent Guidewire Techniques parallel wire techniques and extra support backup cathetersSesame open C

25、oncept of Parallel Wire TechniqueTortuousity - Lesion on BendSeesaw: modifyed parallel wire technique8 F guide2 OTW balloons /catheters2 wires slide parallel and are advanced in an alternating mannerSeesaw WiringParallel Wire Method with Double Support CathetersmarkerSeesaw Wiring guide wires can ex

26、change their roles as marker or penetratormarkerCTO at branch:Sesame open (Saito)And entry can still not be found: Sidebranch technique (Katoh)Side Branch Technique Anchoring technique using OTW balloonSubintimal Tracking and Reentry (STAR)techniqueSupportive 8Fr guideCreate or use existing dissecti

27、on in proximal CTO (Miracle, Confianza, etc.)1.5mm balloon into trackWhisper/Pilot 50 with tight “J” tip/”umbrella tip”Advance with balloon support, avoid spinning wire if possibleMay need pilot 150, 200 for proximalUse softest wire possible for distal (whisper)ReentryAnterograde Dissection and Reen

28、trySubintimal Tracking and Reentry (STAR)TipsStiffer polymer wire (“J”) proximally 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 necessaryPTC

29、A pre-stent conservative size, pressures 12 ATMBifurcation stenting only if absolutely necessarySB dissections may be OKDESConsider angiographic followupSubintimal Tracking and Reentry (STAR)Patient SelectionFailure with conventional wire strategies (parallel, see-saw)No retrograde opportunityRelati

30、vely healthy distal vessel beyond CTOMinimal important branches in shear/dissection zone (RCA, OM)Strong clinical indicationThis is final measure, not first measureInterventional techniques Improvement about CTO Miracale 1995Conquest 1999Parallel and seesaw 2000IVUS guide 2001STAR 2003SHOOTING and F

31、ielder 2005 Tornus 2005CART 2005Retrograde approachAnterograde failureBest septal collateral 7F shorter guide catheter 70-90cmACT300 secondsMicrocathter softer and hydrophilic wire CTO Guide Wire Considerations(1)Start with softer guide wiresConsider hydrophilic for sub-total occlusionsConsider hydr

32、ophilic for heavy calciumOtherwise, start with soft, hydrophobic wiresAdvance to stiffer wires carefullyConsider parallel wire techniques if subintimalHydrophobic wires offer best tactile feel of lesionEntryUnfavorableFavorableStump; no entry point; wire will favor side-branchWell defined nipple int

33、o which wire can be directed MIRACLEbros Family Confianza FamilyBetter torque performanceLess torque performanceLess penetration forceBetter penetration forceBetter crushing forceLess crushing forceBetter tactile feelingLess tactile feelingCommon CTO wire characters(2) MIRACLEbros Family Confianza F

34、amilyto 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 from pseudo to true lumen.is more controllableshould be usedto penetrate proximal or distal cap,only when the near target is detected, Confian

35、za 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)Support Catheters1.5mm balloonTransitILT support catheterSpectronetics Quick Cross St Judes Venture deflecting support catheterTornus catheterFacilitate wire exchangeImprove torque response