慢性完全性闭塞的导丝技术介绍课件

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

2、l occlusions are defined as occlusions greater than 3(1) month old with angiographic TIMI 0 or TIMI 1 flowThe Spectrum of Lumen Morphology in CTO: Clinical ChallengesNecrotic coreProteoglycan-richCalcificationLarge recanalizationchannelsInflammationSmall recanalizationchannelsFibrotic plq:Negativere

3、modellingChronic Total OcclusionsWhats Blocking up the Lumen?1. Dense Fibrotic Tissue: COLLAGEN!2. CalcificationNCVIntraluminal CollagenExtracellular Matrix: Collagen, CalciumIncreased fibrocalcific plaques with ageSrivatsa et al, J Am Coll Cardiol 1997:29:955-63 Intraluminal CalcificationAnatomy of

4、 a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesASAHI CONFIANZA 9ASAHI CONFIANZA 9 Tapered Tip Guide WiresCharacteristics:Very stiff tip 9 gm tip loadTapered tip - .009“ (for enhanced penetration)20 cm

5、 radiopacitiy - Joint-less technologyHydrophobic coating Hydrophilic Coating0.014”Radiopaque Spring Coil0.008”PTFEASAHI CONFIANZA Pro “8-20” Tapered Tip Guide WireCharacteristics:Stiffest tip - 20 gmTapered tip - .00820 cm radiopacitiy Joint-less technologyHybrid coating Greatest penetrating force T

6、he combination of a polymer cover and hydrophilic coating provides outstanding lubricity. Tip coils beneath the polymer help facilitate tip shaping.HI-TORQUE PILOTTM Family of Guide wire1. Coronary CTOs have many typesof lesion morphologies.Therefore, we have to use different types of wiresfor diffe

7、rent 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 SelectionMost important considerationsTorque responseTip feel (tactile respon

8、se)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 tip load to purchase fibrous capHydrophilic wiresHydrophilic wires wi

9、th 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 controlSimplifyed sequence of wiresEasy case ( big vessel, straight )Crossit 100Conf

10、ianza 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 locating another channel Tip Shape Is KeyWire tip for CTOCTOStenosisTip 1

11、mmTip 2-3mmAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesGuidewire Operator TechniquesPENETRATIONDRILLING(controlled) SLIDINGDRILLING(controlled)Guidewire Operator Techniques Short tip curv

12、e ( 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 responsesPENETRATIONGuidewire Operator Techniques Similar tip shape and curves a

13、s 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 tactile responsivenessAllways steer towards inner curve ! Twist gently ,

14、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 ManipulationTechniques of CTO Guidewire ManipulationPenetration vs. Con

15、trolled 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 bendsSimultaneous tip rotation and probingAlmost no tactile responseTakes adva

16、ntage 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 CategoriesDRILLING(controlled)CTO Guidewire Categories Abbott CROSS-IT wires (100, 200

17、,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 gmSLIDINGCTO Guidewire Categories Abbott PILOT and Whisper wiresBSC PT wi

18、resCordis SHINOBI wiresAsahi Fielder wiresAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified “Lesion-Specific” CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesDRILLING(controlled)Lesion-Specific CTO Approaches Most CTOs with discrete entry point;after initial

19、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 failure SLIDINGLesion-Specific CTO Approaches Microchannels present or

20、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 Concept of Parallel Wire TechniqueTortuousity - Lesion on BendSeesaw: m

21、odifyed 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 exchange their roles as marker or penetratormarkerCTO at branch:Sesame o

22、pen (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 dissection in proximal CTO (Miracle, Confianza, etc.)1.5mm balloon into trackW

23、hisper/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 ReentrySubintimal Tracking and Reentry (STAR)TipsStiffer polymer wire (“J”

24、) 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 necessaryPTCA pre-stent conservative size, pressures 12 ATMBifurcation stenting on

25、ly if absolutely necessarySB dissections may be OKDESConsider angiographic followupSubintimal Tracking and Reentry (STAR)Patient SelectionFailure with conventional wire strategies (parallel, see-saw)No retrograde opportunityRelatively healthy distal vessel beyond CTOMinimal important branches in she

26、ar/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 Fielder 2005 Tornus 2005CART 2005Retrograde approachAnterograde failure

27、Best 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 hydrophilic for heavy calciumOtherwise, start with soft, hydrophobic wires

28、Advance 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 into which wire can be directed MIRACLEbros Family Confianza FamilyBetter

29、 torque performanceLess torque performanceLess penetration forceBetter penetration forceBetter crushing forceLess crushing forceBetter tactile feelingLess tactile feelingCommon CTO wire characters(2) MIRACLEbros Family Confianza Familyto advance in the hard CTO with tortuosity,to penetrate proximal

30、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, Confianza Family should not be usedto seek the true channel or advance over a

31、 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 responseProvide extra backup to the GuidewireConquering Chronic Total Coronary Occlusions: newest technical approaches TornusVibrating