1. 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

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

3. Etiology of CTO

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

5. Evolution of CTO: extension and organization of the thrombus

6. Histopathologic Data A tapered and short CTO is feasible for PCI
Katsuragawa M. et at. JACC Vol . 21, No :

9. Key of Successful Antegrade Wiring is “Intima Tracking”

10. ×

11. Re-entry into the True Lumen is Really Difficult

15. calcification and tortuosity inside the CTO

17. Antegrade “Loose Tissue” Tracking

18. 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

19. 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.

20. 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)

21. 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

22. Corsair
Corsair

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

26. Antegrade Intentional Intimal Tracking

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

28. Combination of Antegrade Loose Tissue Tracking
And Intentional Intimal Tracking

29. Combination of Antegrade Loose Tissue Tracking and Intentional Intimal Tracking

30. 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

31. 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.

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

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

34. 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

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

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

37. Effort AP, 72 years, male: Proximal RCA CTO

38. Effort AP, 72 years, male: Proximal RCA CTO

39. Effort AP, 72 years, male: Proximal RCA CTO

40. Effort AP, 72 years, male: Proximal RCA CTO

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

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

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

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

45. Sion with Corsair

46. Sion with Corsair

47. Sion with Corsair

48. Sion with Corsair

49. Sion with Corsair

50. Sion with Corsair

51. Corsair Passed through the CTO Body

52. Final Results after Implantation of 2 Nobori Stents

53. Final Results after Implantation of 2 Nobori Stents

54. 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

55. 200mm Radiopaque Spring Coil
Confianza Pro (9gr)
SLIP Hydrophilic Coating
Stainless Core Wire
0.014”
200mm Radiopaque Spring Coil
PTFE Coating 9g

56. 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

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

58. 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)

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

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

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

62. Fielder XT-R could not be Advanced

63. Antegrade Loose Tissue Tracking with Confianza Pro

64. Antegrade Loose Tissue Tracking with Confianza Pro

65. Antegrade Loose Tissue Tracking with Confianza Pro

66. Corsair was Pushed into the CTO Body

67. Confianza Pro could Cross the CTO Body

68. Corsair could Cross the CTO Body

69. Final Results after Implantation of 4 Xience Prime Stents

70. 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.