慢性完全性闭塞的导丝技术介绍课件.ppt

1、Introduction wire techniques of chronic total occlusionsJun Dai,M.D.Coronary disease center Fuwai Hospital CAMS&PUMC BeijingContentsnDefinitionnPathologynAngiography imagingnPCI technical challenge guidewire technology interventional devices revascularization technologyDefinition of CTOnChronic 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:Negativeremo

3、dellingChronic Total OcclusionsnWhats 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 CalcificationnAge of Occlusion

4、nEntrynLengthnTortuousitynCalciumnCollateralsnDistal Vessel SizenIn-stent occlusionndevicesAnatomic Descriptorsof Procedural SuccessAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified“Lesion-Specific”CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesAnatomy of a

5、CTO GuidewireGuidewire Operator Techniques Simplified“Lesion-Specific”CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesHallmarks of a CTO GuidewireTip styles-core-to-tip designs;sometimes tapered Coils and covers-some favor increased radiopacity;jointless coils for improved to

6、rque response;polymer covers for selected applications Core tapers and materials-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 t

7、ip)ASAHI MIRACLEBROS 3ASAHI MIRACLEBROS 4.5ASAHI MIRACLEBROS 6ASAHI MIRACLEBROS 12ASAHI MIRACLEBROS Family Straight Tip Guide WiresnCharacteristics:Core-to-tip design(unique wire drawing process)Non-tapered tip 11 cm of radiopacity Smooth tractability&delivery with Joint-less distal coil technology

8、Hydrophobic coating Increasing tip loads 3-12 gm Excellent tip shape ability&shape retentionASAHI CONFIANZA 9ASAHI CONFIANZA 9 Tapered Tip Guide WiresnCharacteristics:Very stiff tip 9 gm tip load Tapered tip-.009“(for enhanced penetration)20 cm radiopacitiy-Joint-less technology Hydrophobic coating

9、Hydrophilic Coating0.014”Radiopaque Spring Coil0.008”PTFEASAHI CONFIANZA Pro“8-20”Tapered Tip Guide WirenCharacteristics:Stiffest tip-20 gm Tapered tip-.008 20 cm radiopacitiy Joint-less technology Hybrid coating Greatest penetrating forcen The combination of a polymer cover and hydrophilic coating

10、provides outstanding lubricity.n Tip coils beneath the polymer help facilitate tip shaping.HI-TORQUE PILOTTM Family of Guide wireCordis SHINOBI&SHINOBI PlusCTO GuidewiresUnique flattened tip designed to cross subtotal occlusionsFlattened radiopaque coilsSHINOBISHINOBI Plus1.Coronary CTOs have many t

11、ypesof lesion morphologies.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.Guide Wire SelectionMost important co

12、nsiderations1.Torque response2.Tip feel(tactile response)3.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 purc

13、hase 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 controlSimplifyed sequence of wi

14、resEasy case(big vessel,straight)1.Crossit 1002.Confianza proDifficult case(calcifyed,tortuous,smaller)1.Miracle 3g2.Prox.Tortuosity:lubricious wires3.Miracle 4.5-12 g4.Confianza wiresParallel wire:Confianza 6g 12gWhy so difficult to cross it?Sub-Intimal PathQuickTime遣 蒓赦蓆葿蒪蒒蒟 闘恚蓈社蒓赦赡 菣潜敲蓅蒒蒨缮蔷濠侨菫墙菂钦

15、颣髒黔菑臖 avoid following pathavoid following pathavoid following pathavoid following pathof least resistanceof least resistanceof least resistanceof least resistanceWire technique for locating another channel Tip Shape Is KeyWire tip for CTOCTOStenosisTip 1 mmTip 2-3mmAnatomy of a CTO GuidewireGuidewir

16、e Operator Techniques Simplified“Lesion-Specific”CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesGuidewire Operator TechniquesPENETRATIONDRILLING(controlled)SLIDINGGuidewire Operator Techniques n Short tip curve(2mm)at 45-60o;sometimes a proximal secondary curve at 15-30on Co

17、ntrolled rotational tip motion with gentle forward probing n Start with moderate stiffness tips and stepwise increases in tip stiffnessn Premium on tactile responsesGuidewire Operator Techniques n Similar tip shape and curves as drilling techniquen Precise movements of the guidewire tipn Minimal rot

18、ational tip motion with more aggressive directed forward probingn Tip stiffness should penetrate even heavily calcified entry cap(9-12 gms and tapered)n Reduced tactile responsivenessAllways steer towards inner curve!Twist gently,push and pull!Dont inject dye via OTW-catheter!In curved vessels,the o

19、ptimal 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.Controlled DrillingDirectional control of the tip is more precise in“Penetration”is

20、 easier inGuidewire Operator Techniques n Longer and shallower tip shapes and no secondary bendsn Simultaneous tip rotation and probingn Almost no tactile responsen Takes advantage of reduced guidewire surface friction requires polymer cover Anatomy of a CTO GuidewireGuidewire Operator Techniques Si

21、mplified“Lesion-Specific”CTO Guidewire Use AlgorithmsCTO Guidewire DesignCTO Guidewire CategoriesCTO Guidewire Categories nAbbott CROSS-IT wires(100,200,and 300)nAsahi-Abbott MIRACLE Bros wiresnMedtronic PERSUADER wires(3 and 6 gm)CTO Guidewire Categories nAbbott CROSS-IT 400 wirenAsahi-Abbott CONFI

22、ENZA wires(regular and PRO)-9 and 12 gmnMedtronic PERSUADER wire-9 gmCTO Guidewire Categories nAbbott PILOT and Whisper wiresnBSC PT wiresnCordis SHINOBI wiresnAsahi Fielder wiresAnatomy of a CTO GuidewireGuidewire Operator Techniques Simplified“Lesion-Specific”CTO Guidewire Use AlgorithmsCTO Guidew

23、ire DesignCTO Guidewire CategoriesLesion-Specific CTO Approaches nMost CTOs with discrete entry point;after initial attempt with soft(intermediate)wiresn“Workhorse”techniqueLesion-Specific CTO Approaches nBlunt entry pointnHeavily calcified or resistant lesionsnAlternative to“drilling”as workhorse t

24、echnique after initial soft wire failure Lesion-Specific CTO Approaches nMicrochannels present or sub-total occlusion(residual channel)nISR total occlusionsnSome calcified and angulated lesions nSTAR technique(subintimal reentry)Recent Guidewire Techniques nparallel wire techniques and extra support

25、 backup cathetersnSesame open Concept of Parallel Wire TechniqueSeesaw:modifyed parallel wire techniquen8 F guiden2 OTW balloons/cathetersn2 wires slide parallel and are advanced in an alternating mannerSeesaw WiringParallel Wire Method with Double Support CathetersmarkerSeesaw Wiring markerCTO at b

26、ranch:Sesame open(Saito)And entry can still not be found:Sidebranch technique(Katoh)Subintimal Tracking and Reentry(STAR)techniquen Supportive 8Fr guiden Create or use existing dissection in proximal CTO(Miracle,Confianza,etc.)n 1.5mm balloon into trackn Whisper/Pilot 50 with tight“J”tip/”umbrella t

27、ip”n Advance with balloon support,avoid spinning wire if possible May need pilot 150,200 for proximal Use softest wire possible for distal(whisper)n ReentryAnterograde Dissection and ReentrySubintimal Tracking and Reentry(STAR)Tipsn Stiffer polymer wire(“J”)proximally if needed but always softer dis

28、tally“J-bend”media-to-media diametern Runoff vessels are keyn Visualization of target/runoff vessels is keyn Reentry strategyn Dont lose true lumen distal branch,multiple wires if necessaryn PTCA pre-stent conservative size,pressures 12 ATMn Bifurcation stenting only if absolutely necessaryn SB diss

29、ections may be OKn DESn Consider angiographic followupSubintimal Tracking and Reentry(STAR)Patient SelectionnFailure with conventional wire strategies(parallel,see-saw)nNo retrograde opportunitynRelatively healthy distal vessel beyond CTOnMinimal important branches in shear/dissection zone(RCA,OM)nS

30、trong clinical indicationnThis is final measure,not first measureInterventional techniques Improvement about CTO nMiracale 1995nConquest 1999nParallel and seesaw 2000nIVUS guide 2001nSTAR 2003nSHOOTING and Fielder 2005 nTornus 2005nCART 2005Retrograde approachnAnterograde failurenBest septal collate

31、ral n7F shorter guide catheter 70-90cmnACT300 secondsnMicrocathtern softer and hydrophilic wire CTO Guide Wire Considerations(1)Start with softer guide wires Consider hydrophilic for sub-total occlusions Consider hydrophilic for heavy calcium Otherwise,start with soft,hydrophobic wiresAdvance to sti

32、ffer wires carefullyConsider parallel wire techniques if subintimalHydrophobic wires offer best tactile feel of lesionUnfavorableFavorableStump;no entry point;wire will favor side-branchWell defined nipple into which wire can be directedMIRACLEbros Family Confianza Familytorque performanceLess penet

33、ration forceCommon CTO wire characters(2)MIRACLEbros Familyto penetrate proximal or distal cap to puncture from pseudo to true lumento puncture from pseudo to true lumen.isshould be usedto penetrate proximal or distal cap,Confianza Family shouldbe usedtoor Common CTO wire characters(3)Support Cathet

34、ersn 1.5mm balloonn Transitn ILT support cathetern Spectronetics Quick Cross n St Judes Venture deflecting support cathetern Tornus catheterFacilitate wire exchangeImprove torque responseProvide extra backup to the GuidewireConquering Chronic Total Coronary Occlusions:newest technical approaches nTo

35、rnusnVibrating penetrating catheter guidewire systemsnLaser or radiofrequency ablation Bottom line for CTO management n 1.Before starting,weigh the odds by considering the features of high CTO success based on angiography and available clinical information,especially the estimated age of the CTO.2.S

36、elect appropriate initial guidewires,backup support guides and special support catheters for guidewire drilling.3.Attempt standard wires before starting with hydrophilic guidewire.However,if possible,limit creation of large false channels.4.Use new technology sparingly at first,until experience grow

37、s.Concentrate skills in a small group of operators until success rates improve.5.Learn the rules of engagement and know when to quit.Procedural stopping points:n perforationn device exit from the anticipated lumenn evident futility of success after several hours of effort.n fluoroscopic time exceeded 45 minutes,procedure time more than 2 hoursn contrast media loads in excess of 500 cc,it would be wise to stop,and if possible,try again on another day