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

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

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

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　 Unit ; (mm) 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

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

Fielder FC

Shaping of the Wire Tip 1 mm Fielder FC Fielder SION blue XT XT-R ULTIMATE blos 3

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, Pro. Water, 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 ( Run. Through, Whisper) If extremely tortuous, consider a Fielder XT -- or Sion/ Sion Blue in the near future

Sion and Sion Blue Unit ; (mm) Hydrophilic Polymer Coat Rop e Silicon Coat Rop e Actone 0. 014 Inch PTFE Coat Hydrophilic Polymer Coat Actone 0. 014 Inch 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, Run. Through) II. Pilot 200 Or Cross. Boss 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

IMPORTANT CONCEPT: Penetration Power 40, 80, 120, 140 T, 200 T Tip Diameter 0. 012” Tip Stiffness = 4. 0 g Tip Stiffness Area of GW Tip Note: drawing not to scale Area of GW Tip r • Why Penetration Power? – it’s the complete measurement of the guide wire (Tip Stiffness and the Area of the GW Tip)

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 Load/Area of Tip) (kg/in 2) Fielder XT Asahi 1. 2 g 0. 009” 19 CROSSWIRE Terumo 4. 2 g 0. 014” 27 Miracle. Bros 3 Asahi 3. 9 g 0. 0125” 32 Persuader 3 Medtronic 5. 1 g 0. 014” 33 Miracle. Bros 4. 5 Asahi 4. 4 g 0. 0125” 36 Shinobi Cordis 6. 8 g 0. 014” 44 Shinobi Plus Cordis 7. 0 g 0. 014” 45 CROSSWIRE NT Terumo 7. 5 g 0. 014” 49 Persuader 6 Medtronic 8. 0 g 0. 014” 52 Miracle. Bros 6 Asahi 8. 8 g 0. 0125” 72 Persuader 9 Medtronic 9. 1 g 0. 011” 96 Miracle. Bros 12 Asahi 13. 0 g 0. 0125” 106 Confianza Pro 9 Asahi 9. 3 g 0. 009” 146 Confianza Pro 12 Asahi 12. 4 g 0. 009” 195 Tests performed by and data on file at Abbott Vascular (Tip

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 Rota. Wire Floppy 325 cm esp. with Rota. Glide Solution