The Current CTO Toolbox

Transcription

1 The Current CTO Toolbox R. Michael Wyman, MD Director, Cardiac Catheterization Laboratory and Cardiovascular Interventional Research Torrance Memorial Medical Center Torrance, CA

2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Consulting Fees/Honoraria Boston Scientific Abbott Vascular

3 CTO Toolbox The Toolbox from A to Z Regional Availability The Hybrid Toolbox The Parsimonious-est Toolbox

4 Non-CTO Specific Tools Sheaths Guides Balloons/Stents

5 Non-CTO Specific Tools (but used much more commonly in CTO PCI) Guideliner Snares Rotablator Laser

6 Fortified Guide Support

7 En Snare

8 CTO Specific Tools: Guidewires Asahi family: Fielder MiracleBros Confianza Pro Sion Gaia Pilot 200 Specialized: Stingray Superstiff-CP 8-20, Inteer Externalization: Viper Advance, R350, RG3

9 Fielder Wires Fielder AGP Radiopacity 3cm Coil 12 cm Diameter 0.36mm (0.014inch) Length 180cm, 300cm SLIP COAT coated guidewire with polymer sleeve, providing advanced slip performance and trackability for highly stenosed lesion and tortuous vessels. (Tip load 1.0G) More Flexibility Less Support More Fielder FC AGP Radiopacity 3cm Coil 11 cm Diameter 0.36mm (0.014inch) Length 180cm, 300cm SLIP COAT coated guidewire that provides Fine Control over challenging tortuous vessels and highly stenosed lesions. (Tip load 0.8G) More Flexibility Less Support More Fielder XT AGP Radiopacity 16cm Coil 16 cm Diameter 0.36mm (0.014inch) Tip Diameter 0.23mm (0.009inch) Length 190cm,300cm SLIP COAT coated guidewire with polymer sleeve, providing excellent trackability in tortuous vessels. is the first choice guidewire with extreme precision for retrograde approach and for the treatment of complex lesions such as sub-total occlusions and long diffused lesions. (Tip load 0.8G) More Flexibility Less Support More 9

10 Chronic Occlusion Guidewires Miraclebros 6 AG14M060 Radiopacity 11cm Coil 11 cm Diameter 0.36mm (0.014inch) Length 180cm, 300cm This wire is used when Miracle 3 or 4.5 could not cross the lesion due to a lack of tip stiffness. The wire has a tip load of 6g and has high driving force against the tight lesions. (Tip load 6.0G) More Tip Stiffness Less Pushability More Miraclebros 12 AG14M070 Radiopacity 11cm Coil 11cm Diameter 0.36mm (0.014inch) Length 180cm, 300cm This wire is designed with a tip load of 12g and is indicated for complex chronic occlusion cases such as thick, hard fibrous cap and calcifications. (Tip load 12.0G) More Tip Stiffness Low Pushability More 10

11 Chronic Occlusion Guidewires Confianza AG Radiopacity 20cm Coil 20 cm Diameter 0.36mm(0.014inch) Tip Diameter 0.23mm (0.009inch) Length 180cm, 300cm This wire is non hydrophilic coated and tapered to at the tip. The 9g stiff, tapered tip helps to look for micro channels and to penetrate highly stenosed lesions. (Tip load 9.0G) More Tip Stiffness Less Pushability More Confianza Pro AGH Radiopacity 20cm Coil 20 cm Diameter 0.36mm (0.014inch) Tip Diameter 0.23mm (0.009inch) Length 180cm, 300cm Similar structure and tip stiffness as Conquest except that the coil area is SLIP COAT coated which provides greater lubricity while crossing a lesion. The distal ball tip is not SLIP COAT coated to allow it to catch on to the entry point of the lesions. (Tip load 9.0G) More Tip Stiffness Less Pushability More Confianza Pro 12 AGH Radiopacity 20cm Coil 20 cm Diameter 0.36mm (0.014inch) Tip Diameter 0.23mm (0.009inch) Length 180cm, 300cm This wire is designed with a tip load of 12g and is indicated for complex chronic occlusion cases such as thick, hard fibrous cap and calcifications. (Tip load 12.0G) More Tip Stiffness Less Pushability More 11

12 Sion Guidewire Structure Joint-less spring coil Composite Core Radiopaque length :3cm Coating length :28cm(Full coating) Tip load :0.7g 12

13 13 Sion Composite Core ACT ONE Core wire Twist core Six wire rope Hollow tube Coil

14 Fielder XT-A, Fielder XT-R 20mm straight SLIP-COAT Coating 170mm 30mm taper Compatible for retrograde approach ; Length 190cm 0.36mm (0.014 ) 0.26mm (0.010 ) Composite core PTFE Coating Composite Core technology *SLIP-COAT is a trademark of Angiotech BioCoatings Corp. in the U.S. and/or other countries. Anti kinking structure Higher torque performance with W core W-Coil structure Tip load XT-A = 1.0g XT-R = 0.6g

15 Gaia First, Gaia Second Total Length 1900mm SLIP COAT Coating Length 400mm Coil Length 150mm Gaia First:0.010inch Gaia Second:0.011inch 0.014inch *SLIP-COAT is a trademark of Angiotech BioCoatings Corp. in the U.S. and/or other countries. Options allow the operator to choose the appropriate wire for a variety of situations Gaia First Gaia Second Diameter : Tip load :1.5gf Diameter : Tip load :3.5gf Long hydrophilic coating provides smooth manipulation when used in conjuction with a support catheter such as Corsair

16 Pilot 200 Stiff nontapered jacketed Pilot 200 Complex lesion crossing wire Penetrates better than Fielder XT Will advance across the path of least resistance Follow micro-channels if available Will cross over into the subintimal space in fibro-calcific CTOs without microchannels Manages tortuosity, long lesions well Can serve as knuckle wire

17 Externalization Guidewires 330+ cm wires with favorable properties for externalizaton RG3, R350, ViperWire Advance

18 CTO Specific Tools: Microcatheters Corsair Tornus Fine Cross Dual Lumen Venture

19 Microcatheters-Corsair Corsair Catheter Asahi Intecc 135 cm device intended for antegrade support, 150 cm for retrograde Tapered distal tip and ability to spin the device make the corsair a very effective tool in CTO PCI Polyamide elastomer

20 Microcatheters - FineCross

21 Microcatheters:Tornus Doddering devices used in resistant lesions Braided Stainless Steel Catheter for greater support and pushability Cannot hydraulic exchange Threaded stainless steel construction, enables the exchange and support required for treating resistant Chronically Stenosed Lesions. 1mm Distal Radiopaque Marker for easy visualization of the distal tip Tapered Threaded Tip to facilitate lesion entry Excellent Flexibility for tortuous anatomy

22 Venture Catheter

23 Dual lumen catheters

24 CTO Specific Tools: Bridgepoint Dedicated Antegrade Dissection/Re-entry Device CrossBoss Stingray Balloon Stingray Wire

25 Guidewire Port Ratchet Handle 135 cm Working Length 6F GC Compatible Torque Device Lock GW Compatible (OTW) 2.4F Distal Shaft Atraumatic 1 mm (3F) Distal Tip Tracks via FAST Spin Technique Highly torqueable coiled-wire shaft FAST Spin reduces push required

26 2.9F Distal Shaft 135 cm Working Length Compatibility: 6F GC, GW Balloon Inflation Port GW Port Flat shape selforienting balloon 2.5 X 10mm Exit Ports Marker Band

27 .003".007" shaft diameter.014 (.36mm) Tip angle cm (0.36mm) wire 185cm or 300cm Length Geometry is designed for exit port and re-entry into true lumen 145cm extension wire available Hydrophilic coated

28 CTO Toolbox: Regional Availability US/Canada United Kingdom Japan Europe China India Sion/ Corsair X X X X X X XT-A/XT-R Gaia RG3 Bridgepoint X X X X X Limited X Limited X X X X X X (2015)

29 CTO Crossing Strategies Wire Escalation Soft Polymer Jacket Probe (FIELDER FC/XT) Miracle >3g Confianza Pro 12g Miracle 3g Confianza Pro 9g Clear Path and Target CONFIANZA PRO 12g Unclear Path and Target, +Tortuosity PILOT 200 Fielder XT Distal Lumen Fielder FC Pilot Dissection ReEntry Confianza Pro 9g Confianza Pro 12g CROSSBOSS Reverse CART Eurointervention 2011; 6: STINGRAY

30 CTO Crossing Strategies Wire Escalation Gaia 1,2,3? Soft Polymer Jacket Probe (FIELDER FC/XT) Miracle >3g Confianza Pro 12g Miracle 3g Confianza Pro 9g Clear Path and Target CONFIANZA PRO 12g Unclear Path and Target, +Tortuosity PILOT 200 Fielder XT Gaia 1,2,3? Distal Lumen Fielder FC Pilot Dissection ReEntry Confianza Pro 9g Confianza Pro 12g CROSSBOSS Reverse CART Eurointervention 2011; 6: Gaia 1,2,3? STINGRAY

31 The Hybrid Toolbox Guidewires: Wire escalation-fielder FC/XT, Pilot 200, Confianza Pro 12 Microcatheter: Corsair Collaterals- Sion, FC Externalization- Viper, R350 Antegrade Dissection/Re-entry device: Bridgepoint

32 The Parsimonious-est Toolbox Pilot 200, Sion 150 cm Corsair Bridgepoint

33 CTO Toolbox Wide array of wires, catheters, devices available, though some significant regional differences Overabundance of options can make decision making and teaching difficult Hybrid toolbox attempts to focus and simplify, but must be adaptable to innovative technologies