1. The Spectrum of Guide Wires Available to Recanalize CTOs:
How to Choose the Wires
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center, Japan

2. Etsuo Tsuchikane, MD, PhD
DISCLOSURES
Etsuo Tsuchikane, MD, PhD
I have no real or apparent conflicts of interest to report.

3. Guidewire Operator Techniques
DRILLING
(controlled)
PENETRATION
SLIDING

4. Guidewire Operator Techniques
DRILLING
(controlled)
・Utilize the Guide Wire torque to drill in the desired direction.
Penetration force
Torque
>　Improved manipulation intra-lesion
>　Able to avoid wire trapping in plaque
Lubricity
Torque

5. Guidewire Operator Techniques
DRILLING
(controlled)
Enough torque to avoid wire trapping in plaque
Able to change wire direction in plaque
Tactile feedback about lesion (ie., true lumen or pseudo lumen）

6. Guidewire Operator Techniques
DRILLING
(controlled)
Miraclebros　family　（ASAHI）
Miracle3
11cm Hydrophobic coating
tip load ; 3 , 4.5 , 6 , 12g
0.014” diameter design
11cm Hydrophobic coating
Good torque ability for controlled tracking in CTO
Easy to feel tactile response due to hydrophobic coating
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

7. Guidewire Operator Techniques
PENETRATION
・Puncture tough fibrotic or calcified plaques via the stiff tipped wire
Penetration force
Penetration force
>　Necessary to puncture fibrous caps or 　　calcium deposits
Lubricity
Torque

8. Guidewire Operator Techniques
PENETRATION
Able to penetrate/cross hard plaques
Good lubricity intra-lesion

9. Guidewire Operator Techniques
PENETRATION
Confianza PRO family　（ASAHI）
Confianza Pro
0.009”
20cm Hydrophilic coating
Without ball tip
tip load ; 9 , 12g
” tapered tip design
20cm Hydrophilic coating without ball tip
Good penetration force and adequate torque ability
Hydrophilic coating for good lubricity intra-lesion. The ball tip is uncoated to improve tactile feedback.
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

10. HI-TORQUE PROGRESSTM Guide Wires Features
（ABBOTT）
PENETRATION
INTERMEDIATE POLYMER COVER with HYDROPHILIC COATING : Designed to maximize wire maneuverability while in the lesion
HYDROPHOBIC COATING: facilitates device movement over the proximal section of the wire
TAPERED TIP: ”, ”, 0.009”:
Product Overview:
The HI-TORQUE PROGRESS Family of Coronary Guide Wires is the next generation Chronically Stenosed Lesion (CSL) 0.014” wires. HT PROGRESS is a set of five guide wires, designed with a tapered tip and a variety of tip stiffness, for treatment of CSL’s. The wire features uncovered tip coils on the first 5mm of the tip, and a hydrophilic polymer sleeve that extends 29.5cm proximal to the uncovered tip.
プログレスファミリーは、アボットバスキュラーの次世代の慢性狭窄病変用の0.014インチのガイドワイヤーです。プログレスは、５つのガイドワイヤーのセットであり、慢性狭窄の治療の為にテーパーチップと様々なチップ硬度でデザインされています。このワイヤーの特徴は、先端5mmがカバーされていないチップコイルで、カバーされていないチップから29.5cm手元側に親水性コーティングとポリマースリーブが施されています。
5mm EXPOSED TIP COILS:
Uncoated for “true” tactile feel in the lesion
CORE-TO-TIP STAINLESS STEEL: High tensile strength core material and transition less parabolic core eliminates prolapse points and minimizes kinking, delivering reliable steering and control
3 cm radiopaque coils
DRILLING
(controlled)
DRILLING
(controlled)
Test s performed and data on file at Abbott Vascular
Picture is an artists rendition of the guide wire

11. IMPORTANT CONCEPT: Penetration Power
Tip Stiffness = 4.0g
Tip Diameter 0.012”
Tip Stiffness
.004kg/ (3.14*.006”2)
Penetration Power = 40 kg/in2
Area of GW Tip
Note: drawing not to scale
Area of GW Tip r
Penetration Power:
The wire HT PROGRESS 40, 80, 120, 140T and 200T, number is a calculation that defines the wires Penetration Power (tip stiffness in grams divided by the area of the guide wire tip), to assist physicians in choosing the most appropriate guide wire.  For example, if the HT PROGRESS 40 does not cross the lesion, the physician can choose HT PROGRESS 80, confidently knowing the wire has 2x the amount of Penetration Power as the HT PROGRESS 40.
穿通力
プログレス４０、８０、１２０、１４０T、２００Tですが、この数字は、医師が最も適切なガイドワイヤーを選択する際にサポートするために穿通力として定義された計算値です（チップ堅さ（ｇ）をチップ面積で割った値です）。例えば、プログレス40が病変を通過しなかった場合、医師は、PROGRESS80がプログレス40の2倍の穿通力を持つと自信を持って知りながら、プログレス80を選ぶことができます。
Why Penetration Power? – it’s the complete measurement of the guide wire (Tip Stiffness and the Area of the GW Tip)
How is it useful? Penetration Power guides the physician to their next wire.
Picture is an artists rendition of the guide wire 11

12. HI-TORQUE PROGRESSTM Family of Guide Wires
200
HT PROGRESS 200T (13.3g, ø .009” tip)
“T” = Tapered
150
HT PROGRESS 140T (12.5g, ø .0105” tip)
HT PROGRESS 120 (13.9g, ø .012” tip)
100
Penetration Power
HT PROGRESS 80 (9.7g, ø .012” tip)
Penetration Power (suffix of HT PROGRESS):
The wire HT PROGRESS 40, 80, 120, 140T and 200T, number is a calculation that defines the wires Penetration Power (tip stiffness in grams divided by the area of the guide wire tip), to assist physicians in choosing the most appropriate guide wire.  For example, if the HT PROGRESS 40 does not cross the lesion, the physician can choose HT PROGRESS 80, confidently knowing the wire has 2x the amount of Penetration Power as the HT PROGRESS 40.
穿通力（プログレスの末字）
プログレス４０、８０、１２０、１４０T、２００Tですが、この数字は、医師が最も適切なガイドワイヤーを選択する際にサポートするために穿通力として定義された計算値です（チップ堅さ（ｇ）をチップ面積で割った値です）。例えば、プログレス40が病変を通過しなかった場合、医師は、PROGRESS80がプログレス40の2倍の穿通力を持つと自信を持って知りながら、プログレス80を選ぶことができます。 50
HT PROGRESS 40 (4.8g, ø .012” tip)
PROGRESS [PP] (tip stiffness, ø . Tip Diameter)
KEY:
Penetration Power
Tests performed by and data on file at Abbott Vascular
HT PROGRESS tip load values based on new AV Tip Load test 12

13. Penetration Powers for MIRACLEBROS, CONFIANZA and Progress Family
Take out slide
Put a star
Tests performed by and data on file at Abbott Vascular

14. Guidewire Operator Techniques
SLIDING
・ Utilize superior lubricity to probe the lesion for a softer area to 　
　advance the wire
Penetration force
Lubricity
>　Advance due to lubricity rather than push or torque.
Low tip load
> Probing for softer areas in plaque; high tip loads are unnecessary.
Lubricity
Torque

15. Guidewire Operator Techniques
SLIDING
Low profile to cross microchannels
Precise shaping is necessary
High lubricity intra-lesion
Soft tip; will not puncture hard plaque or adventitia

16. Guidewire Operator Techniques
SLIDING
Fielder family （ASAHI）
Fielder　FC
20cm Hydrophilic coating
with plastic jacket
tip load ; 0.8 g
0.014” diameter design
20cm Hydrophilic coating with plastic jacket
Soft tip and good torque characteristics
Appropriate shaft support
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

17. Guidewire Operator Techniques
SLIDING
Fielder family （ASAHI）
Fielder　XT
0.009”
16cm Hydrophilic coating
with plastic jacket
tip load ; 0.8 g
0.009”-0.014” tapered tip design
16cm Hydrophilic coating with plastic jacket
Low profile tip=　0.009”
Precise shaping
High lubricity
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

18. Guidewire Operator Techniques
SLIDING
Comparison with Fielder family
0.014”
1mm
Fielder　FC
0.009”
Fielder　XT

19. Guidewire Operator Techniques
SLIDING
Fielder　XT
Average size of microchannel is 200μm.

20. Guidewire Operator Techniques
SLIDING
Whisper family （ABBOTT）
Hydrophilic coating with plastic jacket
tip load ; LS = 0.7 g, MS = 0.7g
0.014” tapered tip design
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

21. Guidewire Operator Techniques
SLIDING
Pilot family （ABBOTT）
Hydrophilic coating with plastic jacket
tip load ; PILOT50 = 1.3g , PILOT150 = 2.5g , PILOT200 = 3.2g
0.014” tapered tip design
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

22. Guidewire Operator Techniques
SLIDING
CHOICE PT （BOSTON）
tip load ; 1.5g
Full 35cm Hydrophilic coated & Radiopaque
Teflon
Coated
.0055”
.0067”
.0138”
32cm
Stainless Steel Inner Core
PT2 （BOSTON）
tip load ; LS = 1.5g, MS = 2.0g
Stainless Steel Shaping Ribbon & 2cm Radiopaque
LS: 30cm Hydrophilic Coated Polymer Sleeve
MS: 25cm
INCONEL Joint Parts
Nitinol Inner Core
Stainless Steel
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

23. Guidewire Operator Techniques
SLIDING
Comparison with tip load (g) of previous guide wires
3.5
3.0
2.5
2.0
1.5
1.0
0.5
Fielder FC
Fielder XT
Whisper LS
Whisper MS
PILOT 50
PILOT 150
PILOT 200
CHOICE PT
PT 2 LS
PT 2 MS
Examples limited to CTO Wire Market Share Leaders
Reference：Millenium Research Group, 2009

24. Current Antegrade Wiring Strategy for CTO
SLIDING
Fielder, Pilot, Choice

25. Current Antegrade Wiring Strategy for CTO
DRILLING
(controlled)
Fielder, Pilot, Choice
Miraclebros family

26. Current Antegrade Wiring Strategy for CTO
PENETRATION
Fielder, Pilot, Choice
Miraclebros family
Confianza family

27. Current Antegrade Wiring Strategy for CTO
Miraclebros12
Confianza
Fielder XT
Miraclebros3
SLIDING
DRILLING
(controlled)
DRILLING
(controlled)
PENETRATION
Parallel wiring
Unsuccess
(Not advanced)
Failure
(Subintimal tracking)

28. 12th CTO Club www.cct.gr.jp/ctoclub June 11-12, 2010, Toyohashi, Japan
In the next early Summer, we plan toconduct the 8th CTO club in Toyohashi city, Japan. In this course, we can show you around 20 CTO cases in the 2 days. 28