Anatomy of Contemporary CTO Guidewires and Selection Criteria Patrick L. Whitlow, MD Director, Interventional Cardiology Cleveland Clinic

Disclosure of Financial Interests Research support : Abbott Vascular, Edwards LifeSciences Consultant: ICON, Frantz Medical Stockholder: Medtronics, Inc.

HI-TORQUE® and ASAHI® Guide Wires HI-TORQUE® BMW Guide Wires ASAHI® Guide Wires

ASAHI TruTorq™ Technology SINGLE-JOINT Stainless Steel Platinum JOINT-LESS Platinum TruTorq™ Technology incorporates a proprietary method of fusing the stainless steel to the platinum spring coils for a joint-less transition.

Fielder FC　 Unit ; (mm) Urethan + Hydrophilic Polymer Coat ; 200 0.014Inch PTFE Coat It’s difficult to have tactile feelings from a polymer jacket wire such as Fiedler FC! Ochiai

HI-TORQUE WHISPER® MS & WHISPER® ES Polymer cover with transitionless core designed for deliverability and distal access in tortuous anatomy

HI-TORQUE PILOT® 50 Full Polymer cover with Hydrocoat hydrophilic coating for designed for lesion access Tip coils provide soft, shapeable tip and tactile feedback Marker Band Modified RESPONSEASE™ parabolic technology, designed for torque response and control while providing additional support1 .

Pilot Wires Plastic jacketed hydrophilic coating with progressively more aggressive tip strength Pilot 50 < 1 gm Pilot 150 3 gm Pilot 200 4.5 gm Available in 190( DOCable) or 300 cm lengths

Fielder FC 10

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

Collateral Engagement Wire Use a Workhorse wire that has good tip-shape retention and reasonable support to track the support device into an angulated segment without a long leading edge into the collateral. Whisper MS, Runthrough, BMW, ProWater, Pilot 50, etc

Collateral Crossing Wires Usually choose a Polymer Jacket Wire with a soft but Shapeable ~1 gm Tip that is not tapered Fielder FC Pilot 50 ( RunThrough, Whisper) If extremely tortuous, consider a Fielder XT -- or Sion/ Sion Blue in the near future

Sion and Sion Blue Actone Actone Unit ; (mm) Hydrophilic Polymer Coat 0.014Inch Rope Actone PTFE Coat Silicon Coat Hydrophilic Polymer Coat 0.014Inch Rope Actone PTFE Coat

Lesion Crossing Wires Frequently chosen in an escalating strategy of soft/ safe tip first moving up to more powerful tips with more risk of dissection/ exit I. Fielder XT ( Whisper, Pilot 50, RunThrough) II. Pilot 200 Or CrossBoss III. Knuckle Wire (Fielder XT>> Pilot 200) IV. Confianza Pro 12 ( or some operators prefer 9 gm) ( Mir. Bros, Progress, ProVia)

ASAHI® MIRACLEBROS® Family – Straight Tip Guide Wires Characteristics: 11 cm of Radiopacity Joint-Less Technology Increasing Tip Loads 3g-12g Designed for challenging lesions Increasing Support with increased Tip Stiffness Hydrophobic Coating for tactile feedback and smooth device interaction

ASAHI CONFIANZA Pro® – Tapered Tip Guide Wires Tapered Tip Designed for Lesion Crossability ASAHI CONFIANZA PRO® 9 .009” Hydrophobic Coating 19.9 cm Hydrophilic Coating 1 mm Hydrophobic Coating Characteristics: Tip Load – 9.3g / 12.4g Tapered Tip – 0.009” 20 cm Radiopacitiy Joint-Less Technology Hybrid Coating ASAHI CONFIANZA PRO ® 12 .009” Hydrophobic Coating 19.9 cm Hydrophilic Coating 1 mm Hydrophobic Coating

HI-TORQUE PROGRESSTM Guide Wires Features INTERMEDIATE POLYMER COVER with HYDROPHILIC COATING : Designed to maximize wire maneuverability while in the lesion HYDROPHOBIC COATING: facilitates device movement over the proximal section of the wire TAPERED TIP: 0.012”, 0.0105”, 0.009”: 5mm EXPOSED TIP COILS: Uncoated for “true” tactile feel in the lesion CORE-TO-TIP STAINLESS STEEL: High tensile strength core material and transition less parabolic core eliminates prolapse points and minimizes kinking, delivering reliable steering and control Product Overview: The HI-TORQUE PROGRESS Family of Coronary Guide Wires is the next generation Chronically Stenosed Lesion (CSL) 0.014” wires. HT PROGRESS is a set of five guide wires, designed with a tapered tip and a variety of tip stiffness, for treatment of CSL’s. The wire features uncovered tip coils on the first 5mm of the tip, and a hydrophilic polymer sleeve that extends 29.5cm proximal to the uncovered tip. 3 cm radiopaque coils r

IMPORTANT CONCEPT: Penetration Power 40,80,120,140T,200T Tip Stiffness = 4.0g Tip Diameter 0.012” Tip Stiffness Area of GW Tip Note: drawing not to scale Area of GW Tip r Penetration Power: The wire HT PROGRESS 40, 80, 120, 140T and 200T, number is a calculation that defines the wires Penetration Power (tip stiffness in grams divided by the area of the guide wire tip), to assist physicians in choosing the most appropriate guide wire.  For example, if the HT PROGRESS 40 does not cross the lesion, the physician can choose HT PROGRESS 80, confidently knowing the wire has 2x the amount of Penetration Power as the HT PROGRESS 40. Why Penetration Power? – it’s the complete measurement of the guide wire (Tip Stiffness and the Area of the GW Tip) 20

HI-TORQUE PROGRESS Family of Guide Wires Photos 0.012” HT PROGRESSTM 40 / 80 / 120 0.009” & 0.0105” HT PROGRESS TM 140 / 200 Photos property of Abbott Vascular and on file

Penetration Power Calculations Guide Wire  Manufacturer Tip Stiffness (Load) (g) Tip Diameter Penetration Power (Tip Load/Area of Tip) (kg/in2) Fielder XT Asahi 1.2g 0.009” 19 CROSSWIRE Terumo 4.2g 0.014” 27 MiracleBros 3 3.9g 0.0125” 32 Persuader 3 Medtronic 5.1g 33 MiracleBros 4.5 4.4g 36 Shinobi Cordis 6.8g 44 Shinobi Plus 7.0g 45 CROSSWIRE NT 7.5g 49 Persuader 6 8.0g 52 MiracleBros 6 8.8g 72 Persuader 9 9.1g 0.011” 96 MiracleBros 12 13.0g 106 Confianza Pro 9 9.3g 146 Confianza Pro 12 12.4g 195 Tests performed by and data on file at Abbott Vascular

Externalization Wires Need a long wire with reasonable support and pushability, usually with a polymer coating or jacket Viperwire Advance 335 cm peripheral wire Pilot 200 300 cm Fielder FC 300 cm RotaWire Floppy 325 cm esp. with RotaGlide Solution