btk guidewire technology and techniques for complex lesions · 1 btk guidewire technology and...

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BTK Guidewire Technology and Techniques

for Complex Lesions

2017 LINC @ Mt Sinai

June 12-14, 2017

New York, NY

Brian DeRubertis, MD, FACS

Associate Professor of Surgery

UCLA Division of Vascular Surgery

• Abbott Vascular

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 RelationshipCompany

Disclosure Statement of Financial Interest

• Scientific Advisory Board

• Consulting agreement

• Speakers fees / Honorarium

• Medtronic • Scientific Advisory Board

• Consulting agreement

• Speakers fees / Honorarium

• Research support / REALITY Trial Co-PI

• Boston Scientific • CLI Advisory Board

• Cook Medical • Proctoring and Case Review

• Honorarium

Workhorse Specialty

• Soft tip atraumatic wires

• CTO wires

• Device delivery wires

• Access wire

• “Go-to” wires

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(1) Main Categories

BTK Guidewire Technology & Techniques for Complex Lesions

• Versatile• Maneuverable• Durable distal tip• Good support

Properties:

• Access• Sheath delivery• Lesion crossing • Device tracking• “all-around wires”

Uses:

• Terumo Stiff Glide™• Versacore™• HT Command™ ES

Examples:

• Extra-support• Very flexible• High gram tip load• Tapered tip

• Limited specific use• Complex lesion crossing• Device delivery • Intra-cranial work

• HT Connect®250T• HT Spartacore®

• HT Whisper®

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Workhorse Specialty


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WORKHORSE

- Soft, atraumatic tip- Good tactile feedback

- Versatile- Durable

Case Duration

Case Complexity

SPECIALTY- Tapered tip- Higher tip

load- Specific,

limited use

Guidewire Selection Strategy :

Dependent on procedural steps and complexity

Terumo Stiff GlideVersacore

Command ES

Connect 250TSpartacore

Whisper


0.035”

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(2) Three Platforms

0.018”

0.014”

Personal preference vs. different wire for different purposes?


0.035" PLATFORM

• Designed to provide highest

support and stability

• Compatible with iliac

treatment platforms

SFAILIAC BTK

0.035" PLATFORM

• Designed to provide highest

support & stability

• Compatible with most SFA

balloons/stents

0.018" PLATFORM

• Less traumatic

• Well suited to distal

SFA/popliteal

• More steerable and flexible

• Supports lower profile

devices

• Supports Supera

0.014" PLATFORM

• Least traumatic

• Least support

• May be useful in some

situations e.g., re-entry

0.014" PLATFORM

• Most suitable for small

vessels

• Compatible with lowest

profile balloons

0.018" PLATFORM

• Specific feature needed,

i.e., high support, good

device crossing

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Guidewire “Building Blocks”

Component• Core diameter• Core taper/grind• Core material• Tip style• Coils & covers• Coatings

Performance Properties• Steerability• Trackability• Pushability• Crossability• Visibility• Durability• Tactile Feedback

Technical Characteristics• Support ↔

Flexibility • Torque Response• Lubricity• Radiopacity• Force

Transmission

Guidewire Components lead to Technical Characteristics that affect Performance Properties

Core

Coating

Tip


Core Diameter• Diameter affects flexibility, support and torque

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Smaller Diameter = More Flexibility

Larger Diameter = More Support & Torque


Core Taper / Grind• Tracking

• Degree of support

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Shorter taper = More Flexibility

Longer taper = More Support


Tip Style•Affects steering

•Design options

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Core-to-tipPrecise steering and tip control

Stiffer to assist with resistant lesions

Shaping RibbonFlexible

Softer tip, gentle

Allows shape retention


Stenosis or Occlusion

Stenosis

Strategy : True-luminal

0.014 Asahi Miracle Bros

0.014 Abbott Command

0.014 Abbott Fielder XT

Case/Lesion-Based Wire Selection Strategy

Occlusion Morphology

Occlusion

Strategy : 1) True-luminal

2) Sub-Intimal

0.014 Abbott WINN 200T

0.014 Confianza-12

0.018 Abbott Connect Flex

0.018 Abbott Connect 250T

0.018 Asahi Astato-30

Sub-Intimal True Luminal


0.018 Abbott Connect

0.018 Boston Scientific V-18


Stenosis





Wire Characteristics:

- 1:1 torque / maneuverability

- Atraumatic floppy tip / coils

- Tapered tip


• 0.014 Wire shaft

• 0.009 Tapered tip

• 0.8gm Tip load

• Shaping ribbon

• Polymer jacket w/ slipcoat

Asahi Fielder XT


Stenosis








- Tapered tip



• 2.8gm Tip load (3.5mg ES)

• Stainless / nitinol weld core

• Sturdy, shapeable nitinol tip

• Polymer jacket / hydrophilic

Abbott Command / ES


Stenosis








- Tapered tip




OcclusionStenosis






2) Sub-Intimal





0.014 Confianza Pro -12








Occlusion


2) Sub-Intimal





Goal: 1) Cross Lesion 2) Re-Enter Lumen









Occlusion


2) Sub-Intimal






True Luminal


- High penetration power

- High tip load (12gm-30gm)

- Supportive shaft / core

- Pushability over trackability




Occlusion


2) Sub-Intimal






True Luminal






• 12gm Tip load

• 40cm Polymer jacket

• Flexible body, stiff tip

Connect Flex (Abbott)




Occlusion


2) Sub-Intimal






True Luminal






• 30gm Tip load

• 0.013 Tapered tip

• Core to Tip

Connect 250-T (Abbott)


Densely calcified

tibial lesion

CXITM 0.018

Support catheter

Tapered tip of Hi-Torque

ConnectTM250T engaging

lesion


6F 70 cm

RaabeTM Sheath Cook CXITM 0.035

Catheter

Cook CXITM 0.018

Catheter

Abbott Hi-Torque

ConnectTM 250T

0.018”Wire




Occlusion


2) Sub-Intimal




Sub-Intimal


True Luminal









Occlusion


2) Sub-Intimal




Sub-Intimal




- Floppy hydrophilic tip

- Low tip load

- Short taper (for easy

prolapse)


Resistance despite

escalation of wire stiffness

and coaxial support

Switch from CTO wire to

0.014 Command wire for

sub-intimal dissection


Tight guide wire loop in 0.014

Command wire prevents large

dissection channel

Durable polymer-coated Nitinol

wire tip reforms into steerable

floppy tip


True-Luminal Re-Entry Techniques

Retrograde AccessRe-Entry CathetersRe-Entry Catheters

Enteer

Outback

Off-Road


True-Luminal Re-Entry Techniques

Retrograde AccessRe-Entry Catheters Retrograde Access

• Effective wire escalation strategy depends on knowledge of

basic guidewire components and the effect these

components have on wire performance properties

• Proper wire selection combined with use of re-entry

catheters and retrograde techniques can optimize chances

of successful lesion crossing and re-entry in complex BTK

disease

Conclusions

Division of Vascular Surgery

University of California, Los Angeles

UCLA Ronald Reagan Medical Center

Los Angeles, California


Stenosis

Strategy : True-luminal Occlusion Morphology

Occlusion





2) Sub-Intimal





0.014 Confianza-12







Stenosis

Strategy : True-luminal Occlusion Morphology

Occlusion

Long lesion, fully

occluded (either soft

or calcified)

0.035 Terumo Standard Glidewire


0.014 Abbott Fielder XTFocal “skip” occlusions;

Medial/adventitial

calcification with soft core

Strategy : SubintimalStrategy : True-luminal

0.035 Terumo Stiff Glidewire





0.014 Confianza-12





btk guidewire technology and techniques for complex lesions · 1 btk guidewire technology and...

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