Guiding catheters, wires, and balloons equipment and results

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


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


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


3.04.0

5.0

Tip Orientation

Backup Support


Other Key Features

• Torque and tip control• Soft tip• Kink resistance• Variety of shapes • Adequate lumen sizes• Radiopacity


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


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)


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!

Guiding catheters, wires, and balloons equipment and results

Healthcare

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