The Spectrum of Guide Wires Available to Recanalize CTOs: How to Choose the Wires Etsuo Tsuchikane, MD, PhD Toyohashi Heart Center, Japan

Etsuo Tsuchikane, MD, PhD DISCLOSURES Etsuo Tsuchikane, MD, PhD I have no real or apparent conflicts of interest to report.

Guidewire Operator Techniques DRILLING (controlled) PENETRATION SLIDING

Guidewire Operator Techniques DRILLING (controlled) ・Utilize the Guide Wire torque to drill in the desired direction. Penetration force Torque >　Improved manipulation intra-lesion >　Able to avoid wire trapping in plaque Lubricity Torque

Guidewire Operator Techniques DRILLING (controlled) Enough torque to avoid wire trapping in plaque Able to change wire direction in plaque Tactile feedback about lesion (ie., true lumen or pseudo lumen）

Guidewire Operator Techniques DRILLING (controlled) Miraclebros　family　（ASAHI） Miracle3 11cm Hydrophobic coating tip load ; 3 , 4.5 , 6 , 12g 0.014” diameter design 11cm Hydrophobic coating Good torque ability for controlled tracking in CTO Easy to feel tactile response due to hydrophobic coating Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques PENETRATION ・Puncture tough fibrotic or calcified plaques via the stiff tipped wire Penetration force Penetration force >　Necessary to puncture fibrous caps or 　　calcium deposits Lubricity Torque

Guidewire Operator Techniques PENETRATION Able to penetrate/cross hard plaques Good lubricity intra-lesion

Guidewire Operator Techniques PENETRATION Confianza PRO family　（ASAHI） Confianza Pro 0.009” 20cm Hydrophilic coating Without ball tip tip load ; 9 , 12g 0.009-0.014” tapered tip design 20cm Hydrophilic coating without ball tip Good penetration force and adequate torque ability Hydrophilic coating for good lubricity intra-lesion. The ball tip is uncoated to improve tactile feedback. Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

HI-TORQUE PROGRESSTM Guide Wires Features （ABBOTT） PENETRATION 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”: 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. プログレスファミリーは、アボットバスキュラーの次世代の慢性狭窄病変用の0.014インチのガイドワイヤーです。プログレスは、５つのガイドワイヤーのセットであり、慢性狭窄の治療の為にテーパーチップと様々なチップ硬度でデザインされています。このワイヤーの特徴は、先端5mmがカバーされていないチップコイルで、カバーされていないチップから29.5cm手元側に親水性コーティングとポリマースリーブが施されています。 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 3 cm radiopaque coils DRILLING (controlled) DRILLING (controlled) Test s performed and data on file at Abbott Vascular Picture is an artists rendition of the guide wire

IMPORTANT CONCEPT: Penetration Power Tip Stiffness = 4.0g Tip Diameter 0.012” Tip Stiffness .004kg/ (3.14*.006”2) Penetration Power = 40 kg/in2 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. 穿通力 プログレス４０、８０、１２０、１４０T、２００Tですが、この数字は、医師が最も適切なガイドワイヤーを選択する際にサポートするために穿通力として定義された計算値です（チップ堅さ（ｇ）をチップ面積で割った値です）。例えば、プログレス40が病変を通過しなかった場合、医師は、PROGRESS80がプログレス40の2倍の穿通力を持つと自信を持って知りながら、プログレス80を選ぶことができます。 Why Penetration Power? – it’s the complete measurement of the guide wire (Tip Stiffness and the Area of the GW Tip) How is it useful? Penetration Power guides the physician to their next wire. Picture is an artists rendition of the guide wire 11

HI-TORQUE PROGRESSTM Family of Guide Wires 200 HT PROGRESS 200T (13.3g, ø .009” tip) “T” = Tapered 150 HT PROGRESS 140T (12.5g, ø .0105” tip) HT PROGRESS 120 (13.9g, ø .012” tip) 100 Penetration Power HT PROGRESS 80 (9.7g, ø .012” tip) Penetration Power (suffix of HT PROGRESS): 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. 穿通力（プログレスの末字） プログレス４０、８０、１２０、１４０T、２００Tですが、この数字は、医師が最も適切なガイドワイヤーを選択する際にサポートするために穿通力として定義された計算値です（チップ堅さ（ｇ）をチップ面積で割った値です）。例えば、プログレス40が病変を通過しなかった場合、医師は、PROGRESS80がプログレス40の2倍の穿通力を持つと自信を持って知りながら、プログレス80を選ぶことができます。 50 HT PROGRESS 40 (4.8g, ø .012” tip) PROGRESS [PP] (tip stiffness, ø . Tip Diameter) KEY: Penetration Power Tests performed by and data on file at Abbott Vascular HT PROGRESS tip load values based on new AV Tip Load test 12

Penetration Powers for MIRACLEBROS, CONFIANZA and Progress Family Take out slide Put a star Tests performed by and data on file at Abbott Vascular

Guidewire Operator Techniques SLIDING ・ Utilize superior lubricity to probe the lesion for a softer area to 　 　advance the wire Penetration force Lubricity >　Advance due to lubricity rather than push or torque. Low tip load > Probing for softer areas in plaque; high tip loads are unnecessary. Lubricity Torque

Guidewire Operator Techniques SLIDING Low profile to cross microchannels Precise shaping is necessary High lubricity intra-lesion Soft tip; will not puncture hard plaque or adventitia

Guidewire Operator Techniques SLIDING Fielder family （ASAHI） Fielder　FC 20cm Hydrophilic coating with plastic jacket tip load ; 0.8 g 0.014” diameter design 20cm Hydrophilic coating with plastic jacket Soft tip and good torque characteristics Appropriate shaft support Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques SLIDING Fielder family （ASAHI） Fielder　XT 0.009” 16cm Hydrophilic coating with plastic jacket tip load ; 0.8 g 0.009”-0.014” tapered tip design 16cm Hydrophilic coating with plastic jacket Low profile tip=　0.009” Precise shaping High lubricity Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques SLIDING Comparison with Fielder family 0.014” 1mm Fielder　FC 0.009” Fielder　XT

Guidewire Operator Techniques SLIDING Fielder　XT Average size of microchannel is 200μm.

Guidewire Operator Techniques SLIDING Whisper family （ABBOTT） Hydrophilic coating with plastic jacket tip load ; LS = 0.7 g, MS = 0.7g 0.014” tapered tip design Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques SLIDING Pilot family （ABBOTT） Hydrophilic coating with plastic jacket tip load ; PILOT50 = 1.3g , PILOT150 = 2.5g , PILOT200 = 3.2g 0.014” tapered tip design Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques SLIDING CHOICE PT （BOSTON） tip load ; 1.5g Full 35cm Hydrophilic coated & Radiopaque Teflon Coated .0055” .0067” .0138” 32cm Stainless Steel Inner Core PT2 （BOSTON） tip load ; LS = 1.5g, MS = 2.0g Stainless Steel Shaping Ribbon & 2cm Radiopaque LS: 30cm Hydrophilic Coated Polymer Sleeve MS: 25cm INCONEL Joint Parts Nitinol Inner Core Stainless Steel Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Guidewire Operator Techniques SLIDING Comparison with tip load (g) of previous guide wires 3.5 3.0 2.5 2.0 1.5 1.0 0.5 Fielder FC Fielder XT Whisper LS Whisper MS PILOT 50 PILOT 150 PILOT 200 CHOICE PT PT 2 LS PT 2 MS Examples limited to CTO Wire Market Share Leaders Reference：Millenium Research Group, 2009

Current Antegrade Wiring Strategy for CTO SLIDING Fielder, Pilot, Choice

Current Antegrade Wiring Strategy for CTO DRILLING (controlled) Fielder, Pilot, Choice Miraclebros family

Current Antegrade Wiring Strategy for CTO PENETRATION Fielder, Pilot, Choice Miraclebros family Confianza family

Current Antegrade Wiring Strategy for CTO Miraclebros12 Confianza Fielder XT Miraclebros3 SLIDING DRILLING (controlled) DRILLING (controlled) PENETRATION Parallel wiring Unsuccess (Not advanced) Failure (Subintimal tracking)

12th CTO Club www.cct.gr.jp/ctoclub June 11-12, 2010, Toyohashi, Japan In the next early Summer, we plan toconduct the 8th CTO club in Toyohashi city, Japan. In this course, we can show you around 20 CTO cases in the 2 days. www.cct.gr.jp/ctoclub 28