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Advanced Wiring Techniques for Complex femoropopliteal Obstructions Hiroyoshi Yokoi, MD Fukuoka Sanno Hospital Fukuoka, Japan

Advanced Wiring Techniques for Complex femoropopliteal

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Page 1: Advanced Wiring Techniques for Complex femoropopliteal

Advanced Wiring Techniques for Complex femoropopliteal

Obstructions

Hiroyoshi Yokoi, MD

Fukuoka Sanno Hospital

Fukuoka, Japan

Page 2: Advanced Wiring Techniques for Complex femoropopliteal

Disclosure

Speaker name:

..................Hiroyoshi Yokoi...............................................................

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s) Cook, Termo, BSJ,BIRD

I do not have any potential conflict of interest

Page 3: Advanced Wiring Techniques for Complex femoropopliteal

Geographical Scope of EVT Physicians

North America

• 40% VS• 40% IC• 20% IR

Europe

• 30% IC• 50% IR• 20% VS

• 10% IC• 15% IR• 75% VS

• 10% IC• 70% IR• 20% VS

• 30% IC• 35% IR• 35% VS

Asia-Pacific

• 10% IC• 30% IR• 60% VS

• 80% IC• 5% IR• 15% VS

Latin America

• 20% IC• 30% IR• 50% VS

IC; Interventional Cardiologist IR; Interventional RadiologistVS; Vascular Surgeon

• 80% IC• 5% IR• 15% VS

Japanese EVT-CTO wiring techniques developed from PCI

Page 4: Advanced Wiring Techniques for Complex femoropopliteal

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Page 5: Advanced Wiring Techniques for Complex femoropopliteal

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Page 6: Advanced Wiring Techniques for Complex femoropopliteal

Which wire is appropriate for CTO ?

0.014 or 0.018 or 0.035

In Japan, 0.014-0.018 inch guidewire is favorable than

0.035-inch guidewire in CTO intervention

BTK/SFA SFA/Iliac SFA/Iliac

Page 7: Advanced Wiring Techniques for Complex femoropopliteal

How I shape the tip of guidewires?

Page 8: Advanced Wiring Techniques for Complex femoropopliteal

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Page 9: Advanced Wiring Techniques for Complex femoropopliteal

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Page 10: Advanced Wiring Techniques for Complex femoropopliteal

First choice & main GW

Polymer-jacketed GW

・ Regalia XS 1.0・ Chevalier・ Command・ Jupiter FC

Page 11: Advanced Wiring Techniques for Complex femoropopliteal

Standard GW for SFA&BTK intervention

Regalia XS 1.0 (Asahi Intecc)

Page 12: Advanced Wiring Techniques for Complex femoropopliteal

Chevalier 14 Floppy

0.014inch

Radiopaque length 3cm

Polymer Jacket(Coil Inside)12cm

Total length:235cm

PTFE CoatingHydrophilic Coating

Tip weight: 2g

Strong point is “Trackability”Stainless steal shaft

Page 13: Advanced Wiring Techniques for Complex femoropopliteal

Super strong durability

Hi-Torque Command (Abbot)

Page 14: Advanced Wiring Techniques for Complex femoropopliteal

Coil length:8 cm

Hydrophilic coating length:55cm

0.014inch

Total length:235 cm

不透過長:3 cm

NiTi Core Shaft : 55cm SUS Core Shaft

Polymer coating length:39cm(invisible polymer)

Hybrid core system(Niti+SUS)Polymer Jacket

Hydrophilic coating

Page 15: Advanced Wiring Techniques for Complex femoropopliteal

Differences in each PJ-GWs

・ Regalia XS 1.0Basic GW , Safe, Poor durability

・ Chevalier floppyControllable GW; Good Trackability & Pushability

・ HT-CommandStrong durability but slightly stiff (Tip weight; 3g)

・ Jupiter FC/ FC3Balanced (Trackability, pushability & Durability)

Page 16: Advanced Wiring Techniques for Complex femoropopliteal

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Page 17: Advanced Wiring Techniques for Complex femoropopliteal

Treasure is a hydrophilic coated 0.014-0.018” PTA guidewire, which possesses superior torqueability due to its structure using thick stainless steel wires for the spring coil.

70mm 80mm 0.018 inch

150mm (Pt Coil)Hydrophilic Coating PTFE Coating

12g

High torque performance

Good for controlled drilling

From June 2004

Page 18: Advanced Wiring Techniques for Complex femoropopliteal

Detailed characteristics

Composite Core

Micro-cone tip

Tip load 12gf

Balanced power to cross the highly resistant lesions

Mini pre-shape

Balanced support shaft

design

Torque response

Penetrability

Shape retention

Push transmission Easily catches the entry point

of the occluded lesion

Easy directional control

Advantages in the occluded lesion

Page 19: Advanced Wiring Techniques for Complex femoropopliteal

How to handle guidewires for CTO lesions?

• There are 3 types of techniques to manipulate the guide wires :

1) Sliding Technique

2) Controlled Drilling Technique

3) Penetrating Technique

• For the micro-channels present ,1) may be better.

Tapered tip plastic-jacket hydrophilic GW

• For the usual or tortuous lesions, 2) may be better.

Non tapered tip GW or hydrophilic plastic GW

• For the very hard lesions, 3) may be better

Tapered tip GW with strong penetration power

Page 20: Advanced Wiring Techniques for Complex femoropopliteal

Astato is a 0.014-0.018” hydrophilic coated PTA guidewire, which possesses high penetration power with its 30g tip load and tapered design down to 0.013”.

0.013inch0.013inch

30g150mm (Pt Coil)

Hydrophilic coating

High penetration force

Good for penetration

From August 2006

Page 21: Advanced Wiring Techniques for Complex femoropopliteal

Radiopaque 3cm0.014inch

PTFE CoatingHydrophilic Coating

Length:190cm : SUS core

Tip load 45g,100g

25°1mm pre-shaped

Jupiter MAX product spec.

Page 22: Advanced Wiring Techniques for Complex femoropopliteal

CTO Wire Escalation Techniques

Hybrid Sliding-Drilling-Penetration

Sliding (if micro-channel present)

(Polymer jacketed guidewire)

↓Not cross

Controlled Drilling

(Treasure XS 12, Halberd)

↓Not cross

Penetrating

(Astato XS 30,Jupiter 45,MAX)

↓Not cross

Retrograde Approach

Page 23: Advanced Wiring Techniques for Complex femoropopliteal

Intraluminal vs. subintimal

All the effort we do for getting the intraluminal space

using several techniques and devices.

Page 24: Advanced Wiring Techniques for Complex femoropopliteal
Page 25: Advanced Wiring Techniques for Complex femoropopliteal

Rapid Exchange Lumen & OTW Lumen

Dual Lumen Catheter

Rapid Exchange Lumen(0.014inch)

OTW Lumen(0.014inch)

Page 26: Advanced Wiring Techniques for Complex femoropopliteal
Page 27: Advanced Wiring Techniques for Complex femoropopliteal
Page 28: Advanced Wiring Techniques for Complex femoropopliteal
Page 29: Advanced Wiring Techniques for Complex femoropopliteal
Page 30: Advanced Wiring Techniques for Complex femoropopliteal
Page 31: Advanced Wiring Techniques for Complex femoropopliteal
Page 32: Advanced Wiring Techniques for Complex femoropopliteal
Page 33: Advanced Wiring Techniques for Complex femoropopliteal

©2015 ASAHI INTECC CO., LTD.

This document contains confidential or privileged information.

Any distribution, copying or forwarding is strictly prohibited.

AMC-K14095

Micro-cone tipTip load 7.5gf

Deflection and directional control with the balanced penetration force and torque response

Deflection control

Balanced support shaft

design

Composite Core Torque response

Penetration

Push transmission Easily catches the entry point

of the occluded lesion

Easy directional control

Advantages in the occluded lesion

Detailed characteristics

Mini pre-shape Shape retention

Page 34: Advanced Wiring Techniques for Complex femoropopliteal

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Page 35: Advanced Wiring Techniques for Complex femoropopliteal

Scenery of Cath-Laboduring Ultrasound Guided EVT

by courtesy of Miyamoto

Page 36: Advanced Wiring Techniques for Complex femoropopliteal

Guidewire Crossing of CTOsunder Ultrasound Guidance

SFA Just CTO 0.014inch GW

by courtesy of Miyamoto

Page 37: Advanced Wiring Techniques for Complex femoropopliteal

To identify in which direction the true

lumen is present.

Page 38: Advanced Wiring Techniques for Complex femoropopliteal

IVUS-guided parallel wiring

CTO-exit

Page 39: Advanced Wiring Techniques for Complex femoropopliteal

wire preceding

IVUS-guided technique for long SFA CTO

Prox

Mid

Dis

IVUS

preceding

wire preceding

wire preceding IVUS preceding

or

((((

(((( ((((

((((

Page 40: Advanced Wiring Techniques for Complex femoropopliteal

IVUS preceding

SFA-proximal to mid

by courtesy of Kawasaki

Page 41: Advanced Wiring Techniques for Complex femoropopliteal

Wire preceding

by courtesy of Kawasaki

Page 42: Advanced Wiring Techniques for Complex femoropopliteal

Progress of CTO-EVT in Japan

Factors contributing to progress of CTO EVT

• Antegrade approach

0.014-0.018 stiff and taperd CTO wire technology

Imaging Guided approach (Surface echo, IVUS)

• Retrograde approach

Distal site puncture technique

Trans-collateral approach

Page 43: Advanced Wiring Techniques for Complex femoropopliteal

Peroneal puncture Metatarsal puncture Plantar puncture

Page 44: Advanced Wiring Techniques for Complex femoropopliteal

Take Home Message

• EVT for SFA- CTOs is still technically developing.

• Generally, we have to be very flexible to change

our strategy during EVT.

• We have to be familiar with all of the techniques,

which have been developed.

Page 45: Advanced Wiring Techniques for Complex femoropopliteal

Advanced Wiring Techniques for Complex femoropopliteal

Obstructions

Hiroyoshi Yokoi, MD

Fukuoka Sanno Hospital

Fukuoka, Japan