Masahiko Ochiai MD, FACC, FESC, FSCAI Trends in Initial Guidewire Selection: The Concept of Loose Tissue Tracking Masahiko Ochiai MD, FACC, FESC, FSCAI Division of Cardiology and Cardiac Catheterization Laboratories Showa University Northern Yokohama Hospital, Kanagawa, JAPAN

Masahiko Ochiai, MD PhD Honoraria: Abbott Vascular Boston Scientific Corporation Asahi Intecc Co. Terumo Cardiovascular Systems Group

Etiology of CTO

VH Analysis of CTO proximal reference distal reference Guo J, Maehara A, Mintz GS et al. Catheter Cardiovasc Interv 2012 (in press)

Evolution of CTO: extension and organization of the thrombus

Histopathologic Data A tapered and short CTO is feasible for PCI Katsuragawa M. et at. JACC Vol . 21, No. 3 1993: 604-11

Key of Successful Antegrade Wiring is “Intima Tracking”

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Re-entry into the True Lumen is Really Difficult

calcification and tortuosity inside the CTO

Antegrade “Loose Tissue” Tracking

Principle of “Antegrade Loose Tissue Tracking” W ① = wire tip force ② = resistance in loose tissue ③ = resistance in plaque If we can control ① …………... between ② and ③ … ② < ① < ③ Wire easily pass CTO like as wire wish 3 1 2

Antegrade Loose Tissue Tracking Pathological antegrade micro-channels, typical examples of loose tissue inside CTO bory, are frequently invisible by the angiography. It is very difficult to distinguish antegrade micro-channel and bridging collateral. Loose tissue inside CTO body is not always continuous to the distal true lumen. It is sometimes connected to vasa vasorum.

Optimal Wire for Antegrade Loose Tissue Tracking The wire can track loose tissue inside CTO body within a few minutes. If there is no loose tissue at all, the wire should not be advanced into the sub-intimal space (or should not be advanced behind the calcium in the CTO body)

Fielder XT and FC Fielder XT Fielder FC 11cm Spring Coil 3cm Radio-opaque Coil 0.014” 20cm Polymer Sleeve & SLIP COAT® PTFE Coating Stainless Steel Core Fielder XT 16cm Radio-opaque spring coil 16cm Polymer Sleeve & SLIP COAT® 0.009” 3cm 1cm Fielder FC

Corsair Corsair

Hydrophilic polymer coating Corsair Corsair Hydrophilic polymer coating Very flexible tip PTFE inner layer

Antegrade Intentional Intimal Tracking

Confianza Pro (9gr) and Confianza Pro 12gr SLIP Hydrophilic Coating Stainless Core Wire 0.014” 200mm Radiopaque Spring Coil PTFE Coating 12g 9g

Combination of Antegrade Loose Tissue Tracking And Intentional Intimal Tracking

Combination of Antegrade Loose Tissue Tracking and Intentional Intimal Tracking

We can be very aggressive in antegrade approach! If retrograde approach is applied, sub-intimal space can be used for IVUS guided reverse CART! We can be very aggressive in antegrade approach! Courtesy of Dr S Sumitsuji

Torque Whip Torque whip is the term we use to describe when the rotation at the proximal end of the wire builds up without transmitting to the distal end. The torque is transmitted all at once, and the distal end spins without being able to control it.

ASAHI SION Family Unique GW structure ; Double-coil structure 0.014” Coil type workhorse GW Good torque response - “No whip” motion Tip Durability

Hydrophilic coating ;28cm SION Hydrophilic coating ;28cm 0.014” Full Hydrophilic coating Tip load ; 0.7g

Hydrophilic coating ;18.5cm SION blue ※Not CE Approved Hydrophilic coating ;18.5cm Silicon coating ;1.5cm 0.014” Hybrid coating ; Silicon 1.5cm + Hydrophilic coating 18.5cm Tip load ; 0.5g

Torque Response R5 R70 CCW GW Test　Method “Whip motion”

Shaping of the Wire Tip 1mm Fielder FC Fielder SION SION blue XT XT-R ULTIMATE blos3

Effort AP, 72 years, male: Proximal RCA CTO

Effort AP, 72 years, male: Proximal RCA CTO

Effort AP, 72 years, male: Proximal RCA CTO

Effort AP, 72 years, male: Proximal RCA CTO

Effort AP, 72 years, male: Proximal RCA CTO January 2011 Taipei

Effort AP, 72 years, male: Proximal RCA CTO January 2011 Taipei

Effort AP, 72 years, male: Proximal RCA CTO 8Fr Mach1 IM-SH 6Fr JL4.0 (diagnostic)

Effort AP, 72 years, male: Proximal RCA CTO 8Fr Mach1 IM-SH 6Fr JL4.0 (diagnostic)

Sion with Corsair

Sion with Corsair

Sion with Corsair

Sion with Corsair

Sion with Corsair

Sion with Corsair

Corsair Passed through the CTO Body

Final Results after Implantation of 2 Nobori Stents

Final Results after Implantation of 2 Nobori Stents

Principle of “Antegrade Loose Tissue Tracking” W ① = wire tip force ② = resistance in loose tissue ③ = resistance in plaque If we can control ① …………... between ② and ③ … ② < ① < ③ Wire easily pass CTO like as wire wish 3 1 2

200mm Radiopaque Spring Coil Confianza Pro (9gr) SLIP Hydrophilic Coating Stainless Core Wire 0.014” 200mm Radiopaque Spring Coil PTFE Coating 9g

Torque force Test Method： 2018/5/29 Torque force Torque gage CCW GW Test Method： Immobilize the GW tip, rotate the GW. The torque gage will measure the force generated. Torque force: Possibility of manipulation with distal tip trapped in lesion

Fine Tip Shaping Miraclebros3 ULTIMATEbros3 Confianza Pro 25% Soldering length is decreased to make a fine scale shaping possible as well.

Enhancement of lubricity Test method Lubricity and its durability are the subjects of the measurement. The resistance is measured through push-pull cycles of the load-applied guidewire. GW Weight （Fixed load） About 60% reduction Slip resistance (gf) test cycles (cyc)

Torque Response Output : Distal tip （°） Input : Proximal End（°） GW R70 CCW GW Test　Method Output : Distal tip （°） Input : Proximal End（°）

Mechanical penetration force Tip load Mechanical Penetration Force (MPF)= Area of tip

Effort AP, 61 years, male: Mid RCA CTO 7Fr Mach1 IM-SH 7Fr Mach1 CLS4.0-SH

Fielder XT-R could not be Advanced

Antegrade Loose Tissue Tracking with Confianza Pro

Antegrade Loose Tissue Tracking with Confianza Pro

Antegrade Loose Tissue Tracking with Confianza Pro

Corsair was Pushed into the CTO Body

Confianza Pro could Cross the CTO Body

Corsair could Cross the CTO Body

Final Results after Implantation of 4 Xience Prime Stents

Initial Wire Selection It is very important to start with a wire which does not show torque whip. The tip load is mainly determined by the resistance in the plaque. According to the current trends in Japan, tapered polymer jacket wire or moderate stiff tapered spring wire will be preferred.