stinis - when to choose and how to use...guidewire basics •appropriate tip shape for lesion/vessel...
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Guidewires, Guide Catheters, andGuidewires, Guide Catheters, andSpecialty Devices:Specialty Devices: When to Choose andWhen to Choose andHow to Use Current TechnologyHow to Use Current Technology
Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions
Program Director, Interventional Cardiology Fellowship
Division of Cardiology
Scripps Clinic
La Jolla, CA
SCRIPPS CLINIC
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Can I Do This??
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But I only feel comfortable with a 6Fr JR4 and a BMW….
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Set Yourself Up for Success!
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What Access Should I Use?
•Radial First!Patient comfort
Less bleeding
Same day discharge, even post-PCI
No need to tie up staff for groin holds
Associated with lower overall cost
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Associated with lower overall cost
Can still do unprotected LM, bifurcations, Rotablator, etc.
•Femoral access for:Highly complex anatomy
Extreme tortuosity, calcification, multiple previous stents, some CTOs
Need for hemodynamic support device
Known radial/brachial/subclavian tortuosity or arteria lusoria
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What Guide Should I Use?
•6 French system:Most radial casesCan place 2 simultaneous balloons but not 2 simultaneous stentsRotablator up to 1.5mm burr (1.75mm really tight)
•7 French system:If you must place simultaneous stentsRotablator up to 1.75mm burr
1.25mm 1.5 mm 1.75 mm 2.0 mm
6 Fr 7 Fr 8 Fr
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Rotablator up to 1.75mm burr
•8 French system:Excellent supportSimultaneous balloons/stentsRotablator up to 2.0mm burr
1.25mm 1.5 mm 1.75 mm 2.0 mm
Left Coronary: XB guidesRight Coronary: JR4, AL1, or AL 0.75Use side holes for RCA guides to minimize pressure dampening
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Extra Backup Guide Cathetervs. Judkins Guide Catheter
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BEWARE OF AL1
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Excellent support, BUT:
Risk of dissection if notcarefully inserted orwithdrawn
Risk of acute AI
Don’t use if ostialdisease is present!
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Ikari Left Guide
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Ikari Left Guide
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•Anomalous RCA
•NSTEMI
•7 guides usedtrying to engagethe RCA!
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the RCA!
LESSON:
Sometimes there isNO off the shelfguide that willwork!
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SOLUTION:
Custom multi-purpose guidecreated with heatgun to allowenough reach toengage RCA
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engage RCA
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•Stent deployed
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•Final Results
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Guidewire Basics
•Appropriate tip shape for lesion/vessel
•Maintain free movement of wire tip at all times
•Avoid undue force…. “Finesse not Force”
•Prolapsing soft wires can aid in avoiding sidebranches
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•Avoid excessive rotation- can damage wire tip or shearoff the tip!
•Don’t lose wire position....
But if you do:● Use caution crossing a previously dilated portion of the
vessel to avoid entering a dissection plane
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Shaping the Guidewire
Wire insideintroducermethod allowssmaller moreprecise bends
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Wire outsideintroducermethod doesnot allow forsmall precisebends
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Shaping the Guidewire
Bend too large for vessel diameter:Effectively functions as a straight wire
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Important shaping considerations:Bends need to match vesselsize/diameter and angulation to besuccessful!
Correct bend for vessel diameter
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Wire Tip Load
•Tip load value (stiffness)gives a numeric value to tipstrength
•Tip load measures how muchforce it takes to “buckle” tip
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force it takes to “buckle” tipof guidewire at 10mm
•Lower numbers= softer tip
•Higher numbers= stiffer tip
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10mm
Wire Tip Load:Can be modified by support catheter
0.7 Gram Tipload at 10mm
“Floppy” tip workhorse wire
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3mm
2.3 Gram Tipload at 3mm
“Floppy” tip workhorse wire is NOWeffectively a CTO wire!!
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Coils vs. Polymer Jacket
Exposed Outer Coils: Polymer Cover:
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Exposed Outer Coils:
• Soft, Atraumatic• Provide more tactile
feedback
• Less crossability• Less trackability
Polymer Cover:
• More crossability• More trackability
• Less tactile feedback• More likely to dissect or
perforate
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Outer Spring Coils:Provide tactile feedback at the expense of friction
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Dissection of LAD from attemptedwiring with polymer jacketed wire
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Specialty Wires: Sion
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Specialty wire engineered for wiring collateral vessels forretrograde CTO intervention, but can be used for tortuosity also
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Sion: Longer Taper
Sion Wire: Core Taper
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Standard Workhorse Wire: Shorter Taper
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Specialty Wires: Wiggle Wire
Wiggle Wire
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Deflect tip of device todislodge from obstruction
Reorient tip to aid indelivery of device
Anchors guide catheter
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How Does the Wiggle Wire Work?
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Guidewires: What’s New?
Abbott’s Powerturn Series
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Guide Extension Catheters
GuideLiner (Vascular Solutions) Guidezilla II (Boston Scientific)
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• No outer hydrophilic coating• Transition “half pipe” not easy
to see and can significantlyinteract with stents
• Outer hydrophilic coating• Transition easy to see, less
interaction with devices
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HOW NOT TOUSE A GUIDEEXTENSIONCATHETER!
PART 1
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PART 1
DO NOT injectforcefully when theguide extensioncatheter is deepseated or thepressure isdampened!