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

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Can I Do This??

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But I only feel comfortable with a 6Fr JR4 and a BMW….

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

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

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!

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!

SOLUTION:

Custom multi-purpose guidecreated with heatgun to allowenough reach toengage RCA

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engage RCA

•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

Shaping the Guidewire

Wire insideintroducermethod allowssmaller moreprecise bends

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Wire outsideintroducermethod doesnot allow forsmall precisebends

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

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

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!!

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

Outer Spring Coils:Provide tactile feedback at the expense of friction

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Dissection of LAD from attemptedwiring with polymer jacketed wire

Specialty Wires: Sion

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Specialty wire engineered for wiring collateral vessels forretrograde CTO intervention, but can be used for tortuosity also

Sion: Longer Taper

Sion Wire: Core Taper

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Standard Workhorse Wire: Shorter Taper

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

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

HOW NOT TOUSE A GUIDEEXTENSIONCATHETER!

PART 1

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PART 1

DO NOT injectforcefully when theguide extensioncatheter is deepseated or thepressure isdampened!