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| {{CMG}}; '''Associate Editor-In-Chief:''' Priyantha Ranaweera [mailto:pranawee@bidmc.harvard.edu]; | | {{CMG}}; '''Associate Editor-In-Chief:''' Priyantha Ranaweera [mailto:pranawee@bidmc.harvard.edu]; |
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| '''''Key Words and Synonyms:''''' PCI guidewire, angioplasty guidewire, coronary guidewire, steerable wire, steerable guidewire | | '''''Key Words and Synonyms:''''' PCI guidewire; angioplasty guidewire; coronary guidewire; steerable wire; steerable guidewire. |
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| ==[[Guidewire overview|Overview]]== | | ==Overview== |
| | Angioplasty guidewires are small, soft, flexible, lubricated, wires that act as a rail over which equipment such as an angioplasty balloon, a stent, or an intravascular ultrasound device can be delivered over into the coronary artery. Angioplasty guide wires were introduced in 1982 by doctors Simpson and Roberts. The introduction of coronary guidewires was a major advance as it allowed the angioplasty balloon to be a traumatically steered to the proper location. |
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| ==[[Guidewire historical perspective|Historical Perspective]]== | | ==[[Guidewire general techniques|Guidewire Techniques]]== |
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| | ==[[Guidewire complications|Guidewire Complications]]== |
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| ==[[Guidewire desirable performance characteristics|Desirable Performance Characteristics of Coronary Guidewires]]== | | ==[[Guidewire desirable performance characteristics|Desirable Performance Characteristics of Coronary Guidewires]]== |
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| ==[[Guidewire complications|Guidewire Complications]]==
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| ==Guidewire Design Features== | | ==Guidewire Design Features== |
| | | A guidewrie has three main components - a core, a tip and a lubricous Coating. |
| [[Guidewire core diameters]] | [[Guidewire tip diameters]] | [[Guidewire lengths]]
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| ==[[List of Guidewires by Manufacturer]]==
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| ===PHYSICAL CHARACTERISTICS===
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| Has three main components - Core, Tip and the lubricous coating.
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| [[Image:Components_of_a_guide_wire.jpg]] | | [[Image:Components_of_a_guide_wire.jpg]] |
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| Figure : Components of a guide wire (courtesy : Abbott vascular inc) | | Figure : Components of a guide wire (courtesy : Abbott vascular inc) |
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| In some wires the core extends up to the tip. In others the tip is made of a different material
| | [[Guidewire Core]] | [[Guidewire Coatings]] | [[Guidewire Tip]] |
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| ===CORE===
| | [[Guidewire Core Diameters]] | Guidewire Wisdom | [[Guidewire Tip Diameters]] | [[Guidewire Lengths]] |
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| The core is usually ground to a taper towards the end for the tip to attach.
| | ==Guidewires Classified Based Upon Support (Steerability and Trackability)== |
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| If core starts tapering more towards the tip, the wire as a whole becomes more rigid, steerable and torquable.
| | ===Soft Guidewires=== |
| | [[Guidewire Asahi soft| Asahi Soft Guidewire]] | Hi-torque Balance |
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| The opposite happens when the core tapers more proximally allowing for a longer tip.
| | ===Moderate Support Guidewires=== |
| | [[Guidewire wisper wire|Wisper Wire]] | [[Guidewire High torque balance middle weight|High Torque Balance Middle Weight]] |
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| The core may be continuous or joined (more likely to bend on wire advancement if joined)
| | ===Extra Support Guidewires=== |
| | [[Guidewire choice PT extra support|Choice PT Extra Support]] | PT Graphix Intermediate | Stabilizer | [[Guidewire hi-torque balance heavy weight|Hi-Torque Balance Heavy Weight]] |
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| ====COMPOSITION==== | | ===Super Extra Support Guidewires=== |
| | [[Guidewire iron man|Iron Man]] | [[guidewire asahi grand slam|Asahi Grand Slam]] |
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| Nitinol, stainless steel or similar metal
| | ==Guidewires Classified By Crossing Profile== |
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| ====TYPES OF CORE MATERIAL==== | | ===Complex lesions and lesions in very tortuous vessels=== |
| | [[Guidewire prowater|Prowater]] | [[Guidewire Choice PT|Choice PT]] | PT Graphix Intermediate |
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| ====NITINOL==== | | ===Guidewires Used to Cross Chronic Total Occlusions=== |
| | Wires to be used in escalating order of aggressiveness: |
| | ====First Choice==== |
| | '''Non-hydrophilic''' or '''hydrophobic''' wires with an '''intermediate stiffness''' are a good first choice as they have a better tactile response, are less likely to lead to a subintimal position than a hydrophilic wire, and may have an additional advantage in their ability to cross the proximal cap of the occlusion. Choices in this class include the [[Miracle Bros]] 3 and the [[Asahi intermediate wires]]. |
| | ====Second Choice==== |
| | '''Hydrophilic''' wires may track better after the proximal cap of the occlusion has been crossed. Hydrophilic/coated wires have better maneuverability in [[tortuosity|tortuous]] or [[calcification|calcified]] vessels. '''Intermediate stiffness hydrophilic wire''' choices include the [[Choice PT XS (Extra Support)]], the [[Pilot 50]], the [[Pilot 100]] or the [[PT Graphix intermediate wire]]. |
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| [[Image:nitinol.jpg]] | | ====Third Choice==== |
| | '''Stiff non-hydrophilic wires''': The [[Miracle Bros]] 6, 9 and 12, [[Cross-IT]], [[Confienza]], [[Persuader]] |
| | ====Fourth Choice==== |
| | '''Stiff and hydrophilic (most aggressive)''': [[Pilot 200]] and [[Shinobi]] |
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| ====ADVANTAGES - NITINOL==== | | ==Device Delivery Guidewires== |
| | Guidewire wiggle wire- The wiggle wire has a niche role in delivering stents and balloons into areas with poor transmission of proximal push. The wiggle wire works by shifting the direction of the pushing forces thus "stepping over" the obstacle. |
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| Super-elastic alloy designed for kink resistance
| | ==Peripheral Arterial Guidewires== |
| Excellent flexibility and steering
| | * Spartacore - The Spartacore is a peripheral arterial guidewire. |
| Probably more durable nature
| | * Guidewire V 18 |
| Better trackability
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| Less prolapse.
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| ====DISADVANTAGES - NITINOL=== | | ==Guidewire Tourquing Device== |
| | A torquing device is a tool interventional cardiologists use to torque a coronary guidewire and to maintain the tension on the guidewire to preserve the torque and the direction the guidewire. There is a gradual inadvertent “unwinding” of torque when the human fingers are used to steer a coronary guidewire, and this unwinding can be effectively prevented by this tool. |
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| Stores torque without necessarily transmitting it to the tip Wires with single nitinol cores could “ wind up”
| | ==[[List of Guidewires by Manufacturer]]== |
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| Less torquable
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| ====CLINICAL CORRELATION - NITINOL==== | |
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| Nitinol wires are more likely to enter a retroflexed circumflex
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| ====STAINLESS STEEL====
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| Original core material technology
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| [[Image:stainless_steel.jpg|(Courtesy of Abbott vascular)]]
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| ===ADVANTAGES – STAINLESS STEEL====
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| Gives more pushability, torquability, and good shapeability in “core-to-tip” wires.
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| Good support, push force and torque
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| ====DISADVANTAGES – STAINLESS STEEL====
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| *Tendency to kink
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| *Less flexible than newer core materials
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| ===OTHER MATERIAL USED IN THE CORE===
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| ===High tensile strength stainless steel===
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| [[Image:High_tensile_strength_stainless_steel.jpg]] | |
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| *More durable than regular stainless steel
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| *Retains shape more
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| *Improved flexibility
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| *Improved steering and tracking
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| ===Asahi Tru Torque Steel===
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| [[Image:Asahi_Tru_Torq_Steel.jpg]]
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| ==LUBRICIOUS COATING==
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| One or both of
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| *Hydrophilic
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| *Hydrophobic
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| *Hydrophobic tip and hydrophilic distal end
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| *Affects lubricity, friction and wire tracking in crossing lesions as well as during stent and balloon delivery.
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| *Facilitate smooth movement
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| *Confined to the distal 30-35 cm
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| ==Commonly used coatings==
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| 1.PTFE (Polytetrafluroehylene) - commonest
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| 2.Teflon
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| 3.Silicone
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| 4.Pro/Pel®, (Medtronic)
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| 5.Hydro-track® (Medtronic)
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| 6.Hydro-coat (Abbott vascular)
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| ===HYDROPHILIC COATING===
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| *attracts water
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| *It is applied over polymer or stainless steel (including tip coils)
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| *Thin, non-slippery solid when dry, needs lubrication to perform
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| *Becomes gel when wet
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| *Reduces friction
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| *Increases trackability
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| ===HYDROPHOBIC COATING===
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| *repels water
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| *Silicone on working area of wire, excluding tip
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| *No actuation/wetting required
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| *Reduces friction
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| *Increases trackability
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| Platinum in the tip for radio-opacity. (usually 3-25 cm length at the tip)
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| ===TIP OF THE INNER CORE WIRE===
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| ===CORE TO TIP GUIDE WIRES===
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| [[Image:core_to_tip.jpg]]
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| When the core is extended to the tip, that increases pushability, precise steering, tip control and torquability. This can be a useful feature for eg. in probing chronic total occlusions.
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| With unibody wires there is more torquability, pushability and tactile feel. With two piece tip wires shaping is easy and the wire is likely to retain the shape “wire memory”
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| ===SHAPING RIBBON===
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| Softer tip allowing shape retention
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| [[Image:shaping_ribbon.jpg]]
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| ===TIP OF THE GUIDE WIRE===
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| ===SPRING COIL TIP===
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| 1. Spring coil - Safer than hydrophilic coated or polymer tip wires - less risk of perforation
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| 2. Distal weld
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| ===SPRING COILS===
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| *Outer coils only
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| [[Image:Spring_coil_outer_only.jpg]]
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| *Tip coil only
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| [[Image:Spring_coil_tip_only.jpg]]
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| [http://www.example.com link title]
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| ===TIP COVER===
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| *Polymer or plastic
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| *Provide lubricity
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| *Smooth tracking through tortuosity
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| [[Image:covers.jpg]]
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| =====POLYMER TIP (COVER)=====
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| Polymer instead of the spring coil with hydrophilic coating
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| Improved trackability with the compromise of reduced tactile feedback / feel
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| Eg: PT Graphix™ Intermediate Guide Wire, ChoICE PT wire
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| =====”COMBINATION” TIPS=====
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| *Tip coils plus
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| *Intermediate coils
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| *Bare core
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| *Plastic cover
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| *Polymer
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| *Polymer over tip coils
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| As lubricity increases the amount of tactile feedback decreases. This partly accounts for the increased risk of perforation with hydrophilic coated wires.
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| [[Image:Relationship_of_lubricity_to_tactile_feedback.jpg|thumb|350px]]
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| Courtesy: Abbott Vascular
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| =====TIP LOAD=====
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| One way of quantifying some of these physical features is by measuring with a strain gauge, the force needed to bend a wire when exerted on a straight guide wire tip, at 1 cm from the tip.
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| Using this method , the tip loads in ascending order are 3gm, 4.5 gm, 6gm, 9 gm and 12 gm (ultra stiff)
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| As stiffness increases the wire becomes prone to perforation
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| =====FLEXIBILITY OF TIP=====
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| =====DETERMINANTS OF TIP FLEXIBILITY=====
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| =====JOINT=====
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| There is one or more joints in the wires with tip material some different to core material.
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| The number of joints and the nature of them influence the clinical performance of the wires. The joints could serve as hinge points and bend during guide wire passage.
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| [[Image:Joint_wire_bends.jpg]]
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| ===[[COMMONLY USED GUIDEWIRES]]===
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| There is no uniform clinical classification of guide wires.
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| A commonly used somewhat crude classification is based on
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| 1. Support ( steerability and trackability. )
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| =====Soft guide wires=====
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| *Asahi soft
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| *Hi-torque balance
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| =====moderate support=====
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| *Wizdom
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| *High torque balance middle weight
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| =====extra support=====
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| *ChoICE PT extra support
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| *PT Graphix intermediate
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| *Stabilizer
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| *Hi-torque balance heavy weight
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| =====Super extra support=====
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| *Iron man
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| *Asahi grand slam
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| 2. Crossing profile
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| 2.1 Simple lesions
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| 2.2 Complex lesions and lesions in very tortuous vessels
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| *Prowater
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| *ChoICE PT
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| *PT graphix intermediate
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| 2.3 Chronic total occlusions
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| *Cross it series
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| *Miracle bro series
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| *Shinobi
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| *Confianza
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| 3. Device delivery wires
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| *Stablizier
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| *Wiggle
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| ===[[COMMONLY USED GUIDE WIRES]]===
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| ===ASAHI SOFT / LIGHT GUIDE WIRE===
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| [[Image:Asahi_soft.jpg]]
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| *Hydrophobic Coating
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| *Soft tip
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| *Flexible body
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| *Support to deliver most interventional devices
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| *Tip load: 0.5 g
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| *Radiopaque length: 3 cm
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| *Outside diameter: 0.014"
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| *Total length: 180 cm – 300 cm
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| ===ASAHI PROWATER AND PROWATER FLEX===
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| Relatively safe guide wire with moderate support.
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| [[Image:Asahi_prowater_and_prowater_flex.jpg]]
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| Source : http://www.abbottvascular.com/
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| *Has a hybrid Coating: Soft hydrophobic tip & hydrophilic working coils. Hydrophilic coating maximizes lubricity to navigate anatomy and hydrophobic coating designed to enhance tactile feel.
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| *Uses “TruTorq” technology - a design that fuses stainless steel to platinum spring coils via a single-joint. (claimed to afford the improved torque response and steerability seen with this wire.)
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| *Tip load: 0.8 g
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| *Radiopaque length: 3 cm
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| *Outside diameter: 0.014"
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| *Total length: 180 cm, 300 cm
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| ===ACS HI TORQUE BALANCED MIDDLE WEIGHT (BMW)===
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| ===ACS HIGH TORQE BALANCE MIDDLE WEIGHT (BMW) UNIVERSAL===
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| Shaping ribbon provides reasonable provision for shape retention & tip softness
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| Intermediate coils at the tip maintain .014" diameter for smooth device delivery
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| *Hydrophobic or Hydrophilic coating for tracking
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| [[Image:Asahi_Tru_Torq_Steel.jpg]]
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| ====HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL====
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| [[Image:BMW_universal.jpg]]
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| Durasteel shaping ribbon material provides added durability and shape retention
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| Intermediate section has both a hydrophilic coating and a polymer cover
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| ===PT GRAPHIX INTERMEDIATE===
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| Figure Source http://www.bostonscientific.com
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| ===ChoICE PT ===
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| Excellent in crossing moderately difficult lesions and negotiating tortuous lesions.
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| [[Image:CPT.jpg]]
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| Crossing guide wire with light rail support.
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| Unibody stainless steel
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| Polymer tip
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| Hydrophilic ICE coating
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| Radioopaque length 35 cm
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| Outside diameter 0.014”
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| Available lengths182cm, 300 cm
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| Compatible with magnet Exchange Device
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| ===ChoICE PT Extra support===
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| Crossing guide wire with extra rail support
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| Figure CPT XS jpg
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| Unibody stainless steel
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| Polymer tip
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| Hydrophilic ICE coating
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| Radioopaque length 35 cm
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| Outside diameter 0.014”
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| Available lengths 182cm, 300 cm
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| Compatible with Magnet Exchange Device
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| ===ChoICE Floppy guide wire===
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| Relatively atraumatic guide wire with light rail support.
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| Figure Choice jpg
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| Unibody stainless steel
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| Spring tip, polymer sleeve
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| ICE hydrophilic coating
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| Radioopaque length 3 cm
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| Outside diameter 0.014”
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| Available lengths 182cm, 300 cm
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| Compatible with Magnet Exchange Device
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| ===ChoICE Extra support===
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| Delivery support wire with extra rail support.
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| [[Image:CPT_XS.jpg]]
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| =====BASIC CONSTRUCTION===== | |
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| Unibody stainless steel core
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| Spring tip, Polymer sleeve
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| ICE hydrophilic coating
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| Radioopaque length 3 cm
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| Outside diameter 0.014”
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| Available lengths 182cm, 300 cm
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| Compatible with Magnet Exchange Device
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| ====WHISPER====
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| [[Image:Whisper.jpg]]
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| Durasteel™ Core-to-tip designed to improve steering, durable shape retention and tactile feedback
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| Full Polymer cover with Hydrophilic coating intended for deliverability and smooth lesion access
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| Responsease™ “transitionless” core grind designed to provide improved tracking and better torque response
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| Tip coils designed to provide softer, shapeable tip and also improve tactile feedback
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| ====STABILIZER EXTRA SUPPORT====
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| ==== WIZDOM====
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| :
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| :
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| =====WIGGLE WIRE=====
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| This wire has a niche role in delivering stents and balloons in to areas with poor transmission of proximal push. It works by shifting the direction of the pushing forces thus "stepping over" the :obstacle".
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| =====IRON MAN GUIDEWIRE=====
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| Stiff wire with poor steerability. Its rigidness is used to straighten vessel segements and allow better transmission of forces pushing balloons or stents. This property comes from the tendency of the wire to retain its shape rather than conform to the contours of the vessel. This feature makes “cheese cutter” effects on the vascular intima at their bends. This some times is demonstrated angiographically by a “pleating artifact” and in extreme situations could lead to a transient “no-reflow” state. ( Figure) Though this wire will allow transmit more force to the balloon or the stent, it could actually make device delivery more difficult in tortuous vessels.
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| ===GUIDE WIRES PRIMARILY USED FOR CHRONIC TOTAL OCCLUSIONS===
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| ===CROSS IT GUIDE WIRES===
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| 1. CROSS IT XT 100
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| Cross it 100 xt
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| Figure source: http://www.abbottvascular.com
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| Tapered tip coil from 0.014" to 0.010" at distal 3 cm
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| Hydrocoat hydrophilic coating of distal 30 cm
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| :
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| 2. Cross it 200 XT
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| Cross it 200 xt
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| 3. Cross it 300 XT
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| Cross it 300 xt
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| ===PILOT WIRES===
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| ===Pilot 50, 150, 200===
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| Figure
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| :
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| ====PERSUADER ====
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| These wires are mainly used to cross challenging chronic total occlusions
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| Core to tip family used mainly for CTOs
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| Figures source http://www.medtronic.com
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| =====PERSUADER 3====
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| Persuader 3jpg
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| ====PERSUADER 6====
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| Persuader 6jpg
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| ====PERSUADER 9====
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| Persuader 9jpg
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| ===ASAHI MIRACLE BRO===
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| These wires are mainly used to cross challenging chronic total occlusions
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| Core to tip guidewires
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| ===ASAHI MIRACLE BRO 3===
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| 1. Asahi miraclebros 3.JPG
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| Tip load: 3 g
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| Radiopaque length: 11 cm
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| Outside diameter: 0.014"
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| Total length: 180 cm
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| 2. Asahi Miraclebro 4.5
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| Asahi miraclebros 45.JPG
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| Tip load: 4.5 g
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| Radiopaque length: 11 cm
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| Outside diameter: 0.014"
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| Total length: 180 cm
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| 3. Asahi Miraclebro 6
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| Asahi miraclebros 6.JPG
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| Tip load: 6 g
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| Radiopaque length: 11 cm
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| Outside diameter: 0.014"
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| Total length: 180 cm
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| 4. Asahi Miraclebro 12
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| Asahi miraclebros 12.JPG
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| Tip load: 12 g
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| Radiopaque length: 11 cm
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| Outside diameter: 0.014"
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| Total length: 180 cm
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| =====STEEL CORE=====
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| ===ZINGER GUIDEWIRE===
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| ===COUGAR GUIDEWIRE===
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| ===THUNDER GUIDEWIRE===
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| =====ASAHI GRAND SLAM=====
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| The tip is very flexible, hence less traumatic, but provides considerable support.
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| Tip load: 0.7 g
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| Radiopaque length: 3 cm
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| Outside diameter: 0.014"
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| Total length: 180 cm, 300 cm
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| Asahi grand slam jpg.
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| =====SPARTACORE=====
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| This wire is mainly used in peripheral interventions.
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| =====V 18=====
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| This is a .018” wire mainly used in the peripheral interventions. It is a stiff wire with excellent torque control, tendency to prolapse and perforation.
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| ====STEERABLE GUIDE WIRES====
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| ====Cordis ATW™ All Track Wire====
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| FIG CORDIS STEERABLE GUIDE WIRE
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| Moderate Support
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| General Purpose
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| Precision Control from Hand to Tip
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| Precise steerability for lesion access
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| Enhanced flexibility for tracking in tortuous vessels
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| Highly lubricious, durable platform for smooth delivery of multiple devices
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| The ATWTM Guidewire atraumatic floppy tip and integrated FLEX-JOINTTM Bond combine for distal flexibility and atraumatic vessel tracking
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| ==== Torquer / steering tool====
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| Used to maintain an achieved torque. There is a gradual inadvertent “unwinding” of torque with human fingers which can be effectively prevented by this tool.
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| Two types are commonly used.
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| ====TIPS IN CROSSING A LESION====
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| 1. Use a bend at the tip of the wire which is roughly the length of the diameter of the vessel proximal to the lesion.
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| 2. If a wire repeatedly fails to cross a lesion,
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| a. Adjust the guide,
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| b. Use a balloon, transit, ultrafuse or twin pass catheter to direct the wire
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| c. modify the bend at the tip.
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| d. change the wire ( check the tip of the wire for evidence of wear and tear)
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| 3. A wire in a balloon or a catheter ( ultrafuse, transit or exchelon) may help guide the wire through the lesion
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| ==SAFETY TIPS==
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| 1. Get used to a few wires to suit most situations
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| 2. Always use the least traumatic wire for the lesion, >90% lesions could be crossed with standard “work horse” wires
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| 3. Until familiar and comfortable, do not rush in to wires which are mote likely to perforate.
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| 4. Avoid bending or buckling the wire
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| 5. Never push a wire, let it find its “track” with
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| 6. A ventricular premature beat could be a suggestion that the wire is off track, withdraw the wire immediately and redirect it.
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| 7. Check every fluro and cine loop for evidence for perforation, embolization and dissection. If the picture quality is poor, then do not hesitate to increase the frame count/radiation to improve it.
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| 8. If there is a suspicion of a perforation, then an emergent Echo should be performed on the table. ( link complications – perforation)
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
