Anatomy of Contemporary CTO Guidewires and Selection Criteria

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

Patrick L. Whitlow, MD Grant Support: Abbott Vascular Off - Label: CTO is an off-label indication for PCI except with Bridge. Point equipment

Typical Modern Guide. Wire Features HI-TORQUE® BMW Guide Wires ASAHI® Guide Wires

HI-TORQUE BALANCE MIDDLEWEIGHT™ Shaping ribbon material provides excellent shape retention & tip softness Intermediate coils: • Maintain. 014" diameter for smooth device delivery • Hydrophobic or Hydrophilic coating for tracking

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

Fielder FC　 Urethan + Hydrophilic Polymer Coat ; 200 0. 014 Inch PTFE Coat It’s difficult to have tactile feelings from a polymer jacket wire such as Fiedler FC! Ochiai

Penetration Power • Important Concept to understand CTO Wire Characteristics TIP Stiffness/ Tip Area • Directly related to Tip Stiffness • Inversely related to Tip Area/Tapering/ size

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, Run. Through) II. Pilot 200 ( Miracle Br 4. 5 gm/ HT Progress 40) III. Knuckle Wire (Fielder XT>> Pilot 200) IV. Confianza Pro 12 ( or some operators prefer 9 gm) ( Mir. Bros, Progress, Pro. Via)

ASAHI® MIRACLEBROS® Family – Straight Tip Guide Wires ASAHI MIRACLEBROS® 3 • Characteristics: – 11 cm of Radiopacity ASAHI MIRACLEBROS® 4. 5 – Joint-Less Technology – Increasing Tip Loads 3 g-12 g – Designed for challenging lesions ASAHI MIRACLEBROS® 6 ASAHI MIRACLEBROS® 12 – 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 • Characteristics: . 009” Hydrophobic Coating 19. 9 cm 1 mm Hydrophilic Coating Hydrophobic Coating – Tapered Tip – 0. 009” – 20 cm Radiopacitiy – Joint-Less Technology – Hybrid Coating ASAHI CONFIANZA PRO ® 12. 009” Hydrophobic Coating – Tip Load – 9. 3 g / 12. 4 g 19. 9 cm 1 mm Hydrophilic Hydrophobic Coating

HI-TORQUE PROGRESSTM Guide Wires Features INTERMEDIATE POLYMER COVER with HYDROPHILIC COATING : TAPERED TIP: 0. 012”, 0. 0105”, 0. 009”: 5 mm EXPOSED TIP COILS: Designed to maximize wire maneuverability while in the lesion HYDROPHOBIC COATING: facilitates device movement over the proximal section of the wire CORE-TO-TIP STAINLESS STEEL: 3 cm radiopaque coils High tensile strength core material and transition less parabolic core eliminates prolapse points and minimizes kinking, delivering reliable steering and control Uncoated for “true” tactile feel in the lesion r

Collateral Engagement Wire • Use a Workhorse wire that has good tipshape 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 Elite, Pro. Water, Pilot 50, etc

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 Marker Band Tip coils provide soft, shapeable tip and tactile feedback Modified RESPONSEASE™ parabolic technology, designed for torque response and control while providing additional support 1 .

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

Wire Tip Shapability/ Durability are Critical Features for CTO Wires • Some wires are much better than others, and some operators are better tip shapers with one particular wire than another • In general need short 30 to 45 degree 38 mm length curve, or double curves manipulated with distance from the support catheter

Fielder FC

Wire tip curve Before Shaping • Fielder After Shaping • Fielder FC • Fielder XT Scale = 0. 1 mm

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 , Run. Through, Whisper, BMW Elite If extremely tortuous, consider a Fielder XT -- or Sion

ASAHI SION Guide Wire Design ® Composite Core (distal portion) 1. Flexible core 2. Twist wire Composite Core Technology (proximal portion) 1. Rope Coil 2. Flexible core 3. Twist wire Stainless steel high tension core 3 cm Radiopaque Joint-less spring coils SLIPCOAT hydrophilic coating coats entire working length of the wire (28 cm) TM Illustrations included are artists renditions. Not drawn to scale.

ASAHI® SION’s Breakthrough Composite Core Technology – Distal Portion Twist Wire Core Wire Coil PROWATER® SION Illustrations included are artists renditions. Not drawn to scale. 23

ASAHI® SION’s Breakthrough Composite Core Technology – Proximal Portion Twist Wire Core Wire Coil PROWATER® Ropecoil SION Illustrations included are artists renditions. Not drawn to scale.

To enhance torqueability Composite Core: Rope Coil Twist Wire Rope Coil also designed to protect the Wire durability Core Wire Coil Ropecoil Illustrations included are artists renditions. Not drawn to scale.