Chapters Transcript Video How Do I Choose My Wire to Cross the Lesion Back to Symposium So I'm gonna talk about um guide wires and specifically how to pick them and how to use them, which is something I think maybe sometimes we don't think as much about. So I'm gonna review properties of guide wires that may aid in selection. I'm gonna discuss the techniques, especially when interluminal crossing is not feasible. So what do we do with our wire techniques when we can't stay intraluminal? and I'll give you a few case examples. Do you mind restarting the timer when you get a moment? Oh, sweet. OK, that one's not working. Um, so general tips, you know, you certainly wanna set goals before the intervention. I think, uh, Doctor Pena said that as well. Um, what sheet size? What am I planning, what devices do I plan to use ahead of time? I would say 80% of my knowledge is done in pre-procedure planning, um, with ultrasound and, and physical exam alone. And so there are some guide wire categories when we think about them. We sort of think about frontline or navigation wires. We think about specialty CTO wires and we think about delivery and support wires. OK, so that's getting through stenosis and occlusions. That's specialty wires to get through really difficult fibrotic collagenous or calcified occlusions, and then it's, OK, now how do I deliver my devices? Obviously the sizes are the most common that we use 014, 018, 035. So when we look at a guide wire, you know, we don't need to be biomechanical engineers, but I do think that some working knowledge does give us a little bit of advantage to select the wires appropriate for the job. And so all wires are components of a core diameter, which is usually stainless steel or Nanol, and they're coated with something, either hydrophilic or hydrophobic materials, Teflon, PTFE, things like that. On top of that, we look at wire taper and wire durability, flexibility, and these are things that we all take for granted, but if you actually look at your wire, they all have different properties. And so what does this mean? And so things like wire tapering and coils means that we may have different ability to deflect in a certain lesion. With hydrophilic and hydrophobic coating, hydrophilic coating will go through anything. It's slippery, right? The problem is it'll go through anything, including the wall, undermining plaque, and so hydrophilic wires are much more likely to dissect, and so you have to kind of watch them a little bit more carefully. Hydrophobic wires, on the other hand, are less slippery, but they have a lot more tactile feedback because they're not just going to go, right? And so it kind of gives you a little bit more resistance of where you should be going in a lesion. And so when you're crossing an occlusion, you may want to switch to a hydrophobic wire to sort of figure out what is that point, what is that microchannel that you're looking for to cross that occlusion. So hydrophilic coating does give you lubricity at the expense of tactile feedback. We talk about tip load and so we talk about for example treasure wires and Eotle wires. Those are a gram tip load and basically what that means is the strength of this tip load. So how much can it penetrate a lesion. So obviously a 40 g tip load, an Estao 40, is going to have much more penetrability than say a treasure 12. Now that said, it also means it can perforate a lot easier and so we have to select these wires based on the lesion we're treating. So what is the moral of the story? The moral of the story is these are all the wires available. In fact, I don't even think this is all inclusive. You don't need them all. Pick a handful and master them. I think this is a good example of, you know, you don't want to be a jack of all trades, master of none. Uh, you really want maybe 3 to 4 to 6 wires, um, that you get really good at, and I think making the mistake of using all of them is, is probably not good. Um, I can tell you my wires, uh, sort of, you know, actually Doctor Pena is the one that taught me this at a conference years ago for aortic iliac. I think the Newton LLT is a really nice wire that a lot of people don't think about, um, and then certainly glide wires, tibial, I typically am sticking to 018, 014, and intramalleolar or intrapedal. I'm almost exclusively. The 014 with Whisper and Glad wire. This is my choice, obviously not yours. Um, we can't talk about wires without talking about catheters, and it's the same thing. You've got to have support. What we say is take the fight to the site, all right? Get really up in that grill. Don't go a mile away and think you're gonna be able to cross. And unfortunately or fortunately. There's a million crossing catheters. You don't need them all. Pick a handful and get really familiar with them, OK? To get into the weeds a little bit, sort of how do we activate wires, um, well, there's different, uh, sort of failure parts, and so sometimes the proximal segment will buckle. This is a chance for you to get the catheter as close to the tip as possible to decrease that buckling. Sometimes you'll get part of the way through, but not all the way through. Think about increasing the tip load. Think about becoming more hydrophilic. Think about another delivery system that can get you stronger in there. You can't even penetrate, can't even start. Well, this is a nice example of maybe increasing the tip load, maybe changing access for Doctor Pena's uh um talk. And then again we have this example where we have a wire cross, can't get anything through. Unfortunately that happens not infrequently. Um, again, retrograde access, different devices, atherectomy devices, um, laser, things like that can be useful in terms of the technique itself. This is called the Janali technique. You can actually drill, sort of form this little loop and drill baby drill through this um calcified lesion. I will say, especially with hydrophilic wires, confirm this is a wire that I got all the way around the pedal loop, all the way to the plantar surface, and I'm like, oh sweet, lunchtime. Well, except it wasn't, right? It was completely perforated the entire way, which is OK. You just back up and redo and you can see I was able to get around the entire loop this time. It's not OK if you angioplasty or stent when you're perforated, but it is OK if you just perforate and just back up most of the time. But you do need to always confirm. Uh, in terms of access, I think Doctor Pena already talked about that. I'm gonna skip that, um. Uh, I do think it's worthwhile becoming familiar with the CTO classification. There are some lesions that are just more favorable in one direction and so it doesn't matter what guide wire you pick. Your guide wire is gonna be more efficacious if you're from the more desirable angle. So there's a lot of patients where we will start pedal or retrograde, all right, um. So what about if I can't cross, I can't stay intraluminal. Well, I think part of that is sort of, you can't try the same thing over and over again, and it's also admitting that maybe what you're doing isn't working, right? Um, and so if you're gonna fail, fail fast. And so that means switching to another device, switching to another wire, or to be honest, more often switching to another access. And so for me this is obviously very quickly pedal. One of the best advice I can give is have this prepped ahead of time. The inertia of stopping a case and saying let's go pedal. Let's let's can we prep that and hearing the techs moan and groan is not worth it. Have everything prepped ahead of time. It's all so you're like, oh, that's not working, let's go, let's move. Pedal access, direct stent sticks, that's all useful, um, you know, obviously there's certainly these other techniques of double balloon. The wires won't cross, and so we do this card or reverse card or double balloon techniques where you're actually subminimal subminimal, a safari, but if you can't connect, you can fenestrate it with these balloons. Um, this is another sort of, uh, can you play that middle slide. There's another technique where you have a balloon from below, sort of this modified reverse cart where you can use a delivery device, I think it's the second one, where you can use a reentry device and stick the balloon again. This wire is not intraluminal, but you can make them intraluminal by. Penetrating into its common channel and you'll see here it's obviously very satisfying. You'll see it pop. Like, at some point, come on, pop it, pop it, pop it, oh, so weak anyway, it popped, um, another technique if you can't get the wire across is this bull's eye technique where you sort of have subminimal subminimal wires, snare on one side, snare on the other. This is actually how we do our DVAs now. um, we will just do a gunlike technique percutaneous, stick through the snare, and then you can sort of floss both wires and get an intraluminal channel. Um, and just in the last minute and a half, a sort of a few case examples, um, aorta iliac again, I usually start with a Newton LLT. If that doesn't work, you know, I'm starting with an 035, but I have very low threshold to switch to 014 or even an tao wire, or excuse me, 018 or an estado wire, um, and that usually works pretty well. Um, here's an example of a patient who has a palpable. DP pulse and a good signal and feels good except for the fact that he's got his ulcer there and so this is orphaned heel syndrome and so this patient is not going to heal his wound even though he's got a great pulse, right? It's just on the other part of the foot and so for these patients I do, you know, I'm a very strong believer of fetal loop revascularization. I do like the whisper wire, um, or in some cases an 014 glide wire advantage. The 014 Glideware advantage is really good to sort of torque through. It's not, if it's not a straight pedal loop, some of them have a little tortuosity to it. That said, it will perforate, um, so you have to be careful with that. And then, um, Um, sort of once you have a pedal loop, you know, how do you, how do you get your wire, right, because your wire is going from the vessel you're not interested in through the vessel you're interested in. So how do you sort of change it? There's sort of 4 different ways that I've come up with. One is you can take a balloon around the loop. I try not to take a lot of devices around a healthy loop otherwise. Um, you can snare it. Um, the other technique is to drag your, can you play that third video please, um, is to drag your wire with a balloon. And so if you look here when you play this video, hopefully. Just click on it? No. OK, that's fine. Um, so basically you inflate the balloon and you can actually drag that other wire, so the wire that you could not get through an antigrade, you're through retrograde, you can inflate a balloon and that wire you couldn't get through, uh, antegrade once you have a, you know, pedal loop inflate a balloon and you'll drag it down and that's a nice technique. Um, and then the last thing is, you know, when you, when you have your wires, make sure you double check. There's such satisfaction about getting a wire where you want it to go that you forget to sort of step back. So this is a pedal loop, except for the fact that that's not what a pedal loop looks like. It's supposed to look like that. This happens to be a wire that went through a tarsal communicating branch, and so your result is gonna be OK, but the truth is that's what the pedal loop should look like, right? And so if you can go around, you'll get a much better result. So, um, again, a hibernating vessels just to say a word on that, you know, it's always worth a try, um, you'd be surprised how often that you see nothing, but actually you can get through and get a good result if you have a nice hydrophilic wire where it can slip or a hydrophobic wire where you need sort of tactile resistance. So, um, and then, you know, we get patients all the time, uh, referred from one vascular specialist, uh, nothing to do but amputation, another vascular specialist, nothing to do but amputation, uh, but with good guide wire selection, with good technique, you can actually treat these patients. I'm gonna skip this case just because it's a longer one, this sort of a, my old slide deck that was, that was loaded up a little bit, um, but in summary, you know, there's lots of devices out there. I think you only have to master a few of them. You don't need to know everything that's true about everything artherectomy, all that stuff. Pick a couple that makes sense to you. Alternative approaches to crossing may make a difference between success and failure, and then you got to have a plan, and a plan means what is the patient, what do they look like, what are their disease, what is their preference, limb, what symptoms do they have, and the anatomy, what's the risk, um, and so all this kind of comes in pre-procedure planning. So thank you very much, I appreciate it. Published Created by
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