Post on 15-Apr-2017
Guiding Catheters, Wires, and Balloons: Equipment and Results
Disclosure
• SB: Medtronic, BSc, Abbott Vascular,Gilead
• Advisory Board: Medtronic, Abbott Vascular, Philips
• All faculty disclosures are available on the CRF Events App and online at www.crf.org/tct
PTCA-Fracturing and Splitting Plaque
Design Characteristics of PTCA Balloons
• Over the wire (OTW)
• Rapid exchange (RX), Monorail
• Perfusion
• Fixed wire
• Cutting balloon
• Scoring balloon-Angiosculpt
Over the Wire (OTW)
• Consists of a balloon catheter with a movable guidewire passing through the entire length of its lumen
• OTW requires 2 operators• OTW provides better pushability• 300 cm steerable wire is typically used• Balloon catheter shafts are typically 145 to 155 cm long• 25% of the system use in the U.S.
Product diagram courtesy of the manufacturer.
Over the Wire (OTW)
Advantages• Ability to change wire without removing catheter• Superior pushability because entire catheter body runs
over wire
Disadvantages• Slightly larger profiles and shaft sizes• Typically needs 2 operators• Can take more time, requiring more fluoroscopy
Rapid Exchange (RX)
• Guidewire exits balloon catheter several centimeters proximal to the distal tip
• Guidewire travels separately from the balloon catheter
• RX allows the operator to fix the wire with one hand & advance the balloon with the other
• Single operator
• 180 through 195 cm steerable guidewire is typically used• 75% of the system use in the U.S. and greater than 95%
in the remainder of the world
Product diagram courtesy of the manufacturer.
Rapid Exchange (RX)
Advantages• Single operator• Allows for quick exchanges over a short guidewire
Disadvantages• Can’t reshape or exchange wire without losing position• Guidewire difficult to place without support of balloon• Pushability may be compromised due to the short wire
lumen
Balloon Overview
Illustrations are artist’s rendition and are not drawn to scale.
Working Length
Proximal Taper
Distal Taper
Tip Length
Tip Entry
Crossing Profile
Balloon Dilatation Catheter Components
2. Tip
3. Markers
5. Catheter Platform
1. Balloon
4. Distal Shaft
6. Coating
Illustrations are artist’s rendition and are not drawn to scale.
Characteristics
5 Key Balloon Attributes
• Entry – pushability and crossability
• Tracking – guidewire compatibility
• Crossability – profiles and transition angles
• Dilatation – balloon material and shoulders
• Withdrawal – rewrap
Definitions
• Nominal - the pressure (in atm.) at which the balloon reaches its stated size
• Rated Burst Pressure - (RBP) pressure at which 99.9% of all balloons will not burst at or below (with 95% confidence interval)
• Working Range - range between nominal and rated burst pressure
Compliance
• Compliant - Diameter increases in ratio with the increase in inflation force (size of balloon may grow beyond the ceiling of clinical safety)
• Non-compliant - Reach and maintain specified size regardless of inflation pressure (little to no flexibility in vessel sizing)
• Semi-compliant - Wide working pressure range with controlled flexibility in balloon sizing
2 4 6 8 10 12 14 16 18 202.5
3
3.5
4
Semi-CompliantNon-CompliantCompliant
atm
mm
Balloon Compliance
Multi-Function
VeryDurable
Multi FunctionHighly Crossable
Ultra-Tight Lesions
TortuousAnatomy Pre-Dil & Post Dil Heavy
Calcification
Balloon Differentiation
Compliant
Semi-Compliant
Marker Bands
• Radiopaque bands are swaggered into the shaft of the balloon to determine balloon placement under fluoroscopy
• Bands can be either dual markers or a single center marker
Product diagram courtesy of the manufacturer.
Balloon Material
POC
PE
Nylon
PET
More Compliant
Less Compliant
Manufacturers use different balloon materials and blends to design their balloon portfolio.
Balloon Angioplasty Results
• Plain old balloon angioplasty (POBA )has a high rate of acute recoil and restenosis rates vary from 10-60% depending on size, diameter, complexity of the lesion and patient related factors.
• The use of the cutting balloon/angioscore have reduced these rates and may be an option for complex procedures and small less important branch vessels when stenting is not desired or to prepare the lesion prior to stenting.
• Currently, PTCA is used traditionally for pre-dilating prior to stenting and post-dilatiation to maximally expand a stent.
• The era of the drug eluting balloon (DEB) is on the horizon and will change therapy depending on future randomized trials
Guide Catheters
Diagnostic Catheter Function
• Vehicle for contrast injection
• Pressure measurement• Angiographic
assessment
Guiding Catheter Function
• Conduit for device & wire transport
• Support for equipment advancement
• Vehicle for contrast injection
• Pressure measurement• Angiographic
assessment
Source: Grossman’s Cardiac Catheterization, Angiography, and Intervention
Basic Catheter Construction
• Materials• Layers• Catheter size
Outer LayerMiddle LayerInner Layer
Catheter Size
• Outer diameter = French size (5-10F)• Inner diameter = Inches (thousandths)• Length = Centimeters (cm)
ID=0.000”OD=F
Length=cm
Curve/Tip Length
3.04.0
5.0
JudkinsLeft
P
S
P = Primary CurveS = Secondary Curve
Tip Length = P to S distance (cm)
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
Curve Length
5.04.0
3.04.0
Lateral Wall Support
3.0
4.05.0
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
3.04.0
5.0
Tip Orientation
Backup Support
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
Other Key Features
• Torque and tip control• Soft tip• Kink resistance• Variety of shapes • Adequate lumen sizes• Radiopacity
Sources: Diagnostic and Therapeutic Cardiac Catheterization; Grossman’s Cardiac Catheterization, Angiography, and Intervention
Access Approach
• Femoral Extensive physician experience Easy catheter manipulation Bleeding at puncture site
• Radial & Brachial Little physician experience More difficult catheter manipulation Infrequent bleeding at puncture site Other possible complications
Source: The Manual of Interventional Cardiology
Aorta Anatomy
Normal
Small
Dilated
Source: The Manual of Interventional Cardiology
Acute
Superior
Inferior
Anterior
Posterior
Vessel Takeoff
Left Coronary Artery Catheter Selection
• Judkins Left JL3 JL3.5 JL4, JL4ST (Short Tip) JL5 JL6
• Amplatz AL1, AL2, AL3
• Multi Purpose (MPA)Source: The Manual of Interventional Cardiology
Right Coronary Artery Catheter Selection
• Judkins Right JR3 JR3.5 JR4, JR4ST (Short Tip) JR5 JR6
• Amplatz AR1, AR2
• Hockey Stick• Multi Purpose (MPA)
Source: The Manual of Interventional Cardiology
Graft Cannulation
Internal Mammary Artery Grafts
Saphenous Vein Grafts
Guide Wires
Guide Wire
Guide Wire
Support
Stiffness
Malleabillity
TorqueControl
Guide Wire
Wire Core
Coat
Tip
Core Material
Advantages• Flexible• Durable
Disadvantages• Store torque• Risk of fracture
NITINOL
Advantages• Support• Push• Torque
Disadvantages• Kink• Less flexible
STEEL
Wire Coating
HYDROPHILLIC
• attracts water • It is applied over polymer or
stainless steel (including tip coils)
• Thin, non-slippery solid when dry, needs lubrication to perform
• Becomes gel when wet • Reduces friction • Increases trackability
HYDROPHOBIC
• repels water • Silicone on working area of
wire, excluding tip • No actuation/wetting required • Reduces friction • Increases trackability
Guide Wire - Coating
NO COATING
HYDROPHOBIC
HYDROPHILLIC
POLYMER ANDHYDROPHILLIC
TACTILE FEEDBACK
LUB
RIC
ITY
Guide Wire - Tip
TIP
LOAD
SHAPE
COATJOINTS
COILS
DESIGN
Tip Design
CORE-TO-TIP SHAPING RIBBON
Wire Selection
Workhorse Wires
• BMW• BMW Universal• Runthrough• Hi-Torque Floppy• Prowater
Extra Support
• ACS Intermediate
• Choice ES• Stabilizer• Wiggle Wire
CTO Wires
• Stiff Miracle Confianza Persuader
• Slippery Fielder FC,XT Pilot 50-200
Balloons, Guides, Wires
• Core products for the Interventional cardiology community
• Each product is critical to the ultimate success of the procedure
• They are used in every case and in many cases several balloons and wires will be utilized
• Enhancements to these products occur regularly and help advance the field
Guiding Catheters, Wires, and Balloons: Equipment and Results
ABC’s of Interventional CardiologyTCT 2014
THANK YOU!