ovascuiar
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`
`Guidewire and
`Catheter Skills for
`Endovascular
`Surgery
`
`Second Edition
`Revised and Expanded
`
`Peter A* Schneider
`
`Edwards Exhibit 1036, pg. 1
`
`

`
`ovascuiar
`s
`
`/,
`
`Guidewire and
`Catheter Skills for
`Endovascular
`Surgery
`
`Second Edition
`Revised and Expanded
`
`Peter A* Schneider
`Hawaii Permanente Medical Group
`Honolulu, Hawaii, U.S.A.
`
`M A R C EL
`
`MARCEL DEKKER, INC.
`
`N EW YORK • BASEL
`
`Edwards Exhibit 1036, pg. 2
`
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`Edwards Exhibit 1036, pg. 4
`
`

`
`Chapter 3
`
`Guidewire-Catheter Skills
`
`33
`
`lasts
`
`iovascular inter-
`theter skills are
`acquired, these
`scular problems.
`.-. However, the
`; of the arterial
`lature. Although
`leters is impor-
`itil the clinician
`ire many correct
`;us may become
`n the success of
`
`specialist's work-
`idewires involves
`)ices, guidewire-
`
`equires a knowl-
`te guidewire first
`arst choice turns
`able. Rather than
`' guidewires, that
`
`)f guidewires re-
`1 with which the
`:e and success of
`
`the process of
`m between
`the
`c imaging as the
`in vivo requires
`;uidewire-lesion
`)n of guidewire-
`s that are not
`
`D
`
`E
`
`F
`
`G
`
`H
`
`Fig. 1 Guidewire-lesion interactions. Several possible outcomes may result
`from interaction between the tip of the guidewire and an occlusive lesion. A, A
`guidewire tip approaches a lesion. B, The guidewire traverses the lesion on its first
`pass. C, The guidewire's leading edge catches on the proximal end of the stenosis.
`The floppy tip buckles allowing an elbow of guidewire to traverse the lesion. D, The
`floppy tip begins to buckle but catches on a ledge of plaque and is unable to cross the
`lesion. E, The guidewire tip hits plaque and is unable to find the eccentric lumen.
`F, The guidewire piles up proximal to the lesion. G, The guidewire finds a
`subintimal plane. H, The guidewire disrupts plaque, which results in embolization
`of atherosclerotic material.
`
`Edwards Exhibit 1036, pg. 5
`
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`Edwards Exhibit 1036, pg. 6
`
`

`
`Chapter 3
`
`Guidewire-Catheter Skills
`
`35
`
`provides a two-
`hese situations
`/ire and use of
`
`otn
`
`s each guidewire
`stiffness, coating.
`
`jate to cover the
`tient. The length
`2 to well beyond
`lost during the
`[istance required
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`d the catheter so
`ig. 2). Guidewire
`
`;pecific diameter,
`his specification,
`are 0.035 in. in
`h as aortic stent-
`: angioplasty may
`
`confers differing
`rounding wrap of
`;ntation while the
`
`ire with a layer of
`
`Fig. 2 Guidewire length requirements. Guidewire length requirements are
`represented in diagrammatic form. The length of guidewire required includes A,
`the distance beyond the lesion to secure access across the intended site of
`intervention, B, the distance from the arterial access site to the lesion, C, the
`distance from the hub of the sheath to the puncture site, D, the length of the
`catheter intended for use, and E, the length of guidewire beyond the end of
`the catheter so that hand control may be maintained.
`
`Edwards Exhibit 1036, pg. 7
`
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`
`

`
`Chapter 3
`
`Guidewire-Catheter Skills
`
`37
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`Edwards Exhibit 1036, pg. 9
`
`

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`Edwards Exhibit 1036, pg. 10
`
`

`
`Chapter 3
`
`Guidewire-Catheter Skills
`
`39
`
`second-choice guidewire for a critically stenotic lesion. However, the hydro-
`philic-coated guidewire is so slick when it is wet that the operator often has
`the impression that the guidewire is being advanced when, in fact, it is
`stationary. Occasionally, the guidewire may be withdrawn from the lesion
`without the operator realizing that this movement has taken place. If
`multiple catheter exchanges are required for treatment of a lesion that
`has been crossed with a hydrophilic-coated guidewire, it is often best to
`exchange this guidewire for a stiffer, less mobile one. In addition, because
`of the hydrophilic coating, the guidewire can slide easily along a dissection
`plane, which can be a problem if undetected, especially if a larger
`endovascular device is passed over it.
`
`Another selective, steerable guidewire useful for negotiating turns and
`for selective catheterization is the steerable tip, steel wire (i.e., Wholey;
`Mallinckrodt, Inc., St. Louis, Mo.). Simple manipulation of the end of the
`
`Fig. 3 Tighten the curve on a guidewire tip. The steerable Wholey guidewire is
`useful for selective catheterization and crossing irregular stenoses and occlusions.
`The amount of curvature at the tip of the guidewire can be adjusted using a simple
`maneuver. A, The tip of the Wholey guidewire is trapped between the thumb and the
`edge of a hemostat. B, The guidewire is pulled so that the metal edge of the clamp
`runs along the guidewire, which results in a tighter curvature at the tip.
`
`ddewire is best
`a floppy tip. A
`id is therefore
`ckling when it
`ion is curved or
`
`g lengths of the
`orque 1:1 ratio
`ss of the shaft.
`
`vascular prece(cid:173)
`de 1). Starting
`are the three
`ar intervention,
`ic tasks.
`
`ket. These are
`catheter intro-
`son guidewire
`t has a floppy
`relatively inex-
`3erformed with
`juidewires that
`litech) and the
`
`e branches for
`guidewires are
`> of guidewire
`loley wire. For
`, a hydrophilic-
`iledi-Tech Divi-
`lore difficult to
`firm tip, or a
`ip for crossing
`cannulation of
`-tip hydrophilic
`is the first- or
`
`I
`
`Edwards Exhibit 1036, pg. 11
`
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`Edwards Exhibit 1036, pg. 12
`
`

`
`Chapter 3
`
`Guidewire-Catheter Skills
`
`41
`
`Standard guidewire lengths are 145 to 300 cm. A guidewire length of 145
`cm is adequate for catheter passage when performing general arteriography
`(Table 2). A 180-cm-length guidewire may be required for passage over the
`aortic bifurcation if the catheter is advanced into the contralateral SFA. A 260-
`cm guidewire may be required for arch aortography or carotid arteriography,
`especially in a tall individual. A 260-cm guidewire is required for long
`distances within the vasculature (e.g., brachial artery access to the lower
`extremity) or if the device intended for passage is particularly long (e.g.,
`aortic stent-graft; Fig. 2).
`
`TECHNIQUE: Guidewire Handling
`
`Although choosing the appropriate initial guidewire is the most important decision
`to ensure success, facility with specific maneuvers makes the guidewire knowledge
`clinically applicable.
`
`1. Wet the guidewire with heparin-saline solution. All guidewires function
`better when wet, and hydrophilic-coated guidewires must be wet to
`function at all.
`2. Stiffen the floppy tip of the starting guidewire (Fig. 4) so that it will pass
`through the entry needle hub and into the arterial access site.
`3. Seek alternatives if the guidewire won't pass through the needle (see
`Chapter 2 for plan of attack if the guidewire won't pass through
`the needle).
`
`le steerable tip
`: is locked onto
`s wire is useful
`mcture and for
`for cannulating
`ra body of the
`e the lesion has
`
`md have a firm
`ed (into a side
`ay be enhanced
`guidewire. The
`easier to pass
`[istant passages.
`: (Cook or Bos-
`e Rosen (Medi-
`ald not be used
`ti because it can
`ires, such as a
`it, a stiff guide-
`occlusion or a
`>s likely to pass
`
`in. in diameter.
`are sometimes
`ot be traversed
`7 systems for the
`neter) pass over
`
`1 arteriogram,
`inal aorta and
`ach to infrainguinal
`
`ntions, contralateral
`
`t-graft placement
`
`Fig. 4 Stiffen the floppy tip of the guidewire. A, Floppy-tip guidewires (i.e., the
`Bentson) are relatively atraumatic to the endoluminal surface, but the tip is very
`flexible and sometimes difficult to handle. B, The floppy tip of the guidewire can be
`stiffened by applying one-handed traction to pass it more easily through the hub of
`the needle or catheter. The guidewire is grasped with the thumb and forefinger near
`its leading edge and the third, fourth, and fifth fingers pin the guidewire against the
`palm. Applying traction causes the tip to stiffen and straighten.
`
`Edwards Exhibit 1036, pg. 13
`
`

`
`Edwards Exhibit 1036, pg. 14
`
`

`
`Edwards Exhibit 1036, pg. 15