Experience with a New Guidewire: The Terumo Runthrough NS

Can you tell us about the cath lab at Mount Sinai?
Mount Sinai has a very busy cath lab. In 2003, we did 2,750 interventional procedures (with a total cath volume of 9400). In 2006, we crossed the 5,000 mark (5,174 interventional procedures and total cath volume >14,000), which makes Mount Sinai one of the largest four or five labs in the country to do 5000 interventions. In 2007, we did 4,908 interventional procedures with a total cath volume >14,500. So, in both 2006 and 2007 combined, a total of 5000+ interventional cases each year were done at Mount Sinai cath lab, all in 4.5 rooms (as one room is shared with pediatric cardiology). We have 5 full-time interventionalists and 8 part-time interventionalists as well. The cath lab staff has grown over the last five years, with current number of employees being over 125 (of which 46 nurses and 8 nurse practitioners).
Being a tertiary referral center, our patient population is very high risk. One of the important reasons for our continued growth is extremely good success in these high-risk interventions. In view of concerns about reimbursements, very few labs do ambulatory interventions (same-day discharge), while about 22% of our cases are discharged on the same day. It’s actually good for the institution and helps a great deal, since we don’t have to worry about having beds for each patient.
Mount Sinai has maintained a very impressive track record in the New York area, with high efficiency, good work ethics and excellent procedural outcomes. We believe that the higher the volume for each physician, the better is the outcome. We follow numerous set protocols in the cath lab and do the same thing every time, a key factor that has led to the present success of our cath lab.

What are your criteria for same-day discharge? Do you use radial procedures?
We do about 10% of our procedures with radial access. Two of our voluntary attending do a large percentage (>70%) of their cases via radial approach. The criteria for the same-day discharge are successful interventions, no procedural complications, and no issues in 4-8 hours post-procedure observations and follow-up lab tests.

How long have you been using the Runthrough NS?
For about 2-3 months. For last 10 years, the Balance Middleweight (BMW; [Guidant] Abbott Vascular, Redwood City, CA) has been our main workhorse wire, used in 70% of our cases. Even now, the BMW remains our most-used wire. Aside from the Runthrough, the only wires we have added in the past few years are the Miracle Bros (Asahi) wires for total occlusions and Fielder wire for angulated lesions from Abbott Vascular. We commonly use these specialty wires for tortuous, angulated and total/subtotal coronary lesions. Prior to that, we used to use Boston Scientific Choice and Luge wires (Natick, MA) and Guidant’s Whisper & Pilot wires, but these are now largely replaced with the Fielder wire, which is a very good Abbott wire for these complex lesions. All of this is to say that prior to adopting the Runthrough, we were actually very content with our guidewire situation. We knew that the Runthrough wire was available, but we were not ready to change our wire choice. In attending few of the national meetings, however, I heard all the talk about the Runthrough wire and then was convinced to give it a try. It has worked out very well. We have had a good experience with Runthrough wire in past few months. Prior to the Runthrough, we would use combination of two wires for angulated lesions and tortuous vessels: BMW and Fielder. The BMW is a workhorse wire that gives you good support and the Fielder wire can go through angulated lesions, but may not give that good support. The Runthrough NS now allows us to go through angulated, tortuous lesions and yet it also provides good support for advancement in difficult situations. Usually, you don’t need much support when you are inserting a stent, but in some angulated lesions, upward-curving vein grafts, shepherd’s crook right coronary arteries and tortuous circumflex arteries, you may need an extra body support wire, and the Runthrough NS gives good support for that purpose.

Has it affected your use of specialty wires?
Yes, I know that some interventionalists talk about the Runthrough NS being a workhorse wire, and indeed it has the quality of a specialty wire in giving good support and is able to advance the devices in angulated lesions. In tortuous or angulated lesions, if we need some support, instead of using Fielder wire, we can use only the Runthrough NS wire. Still, we have not yet replaced the BMW in our lab. The BMW is still the main workhorse wire at this time because of its continued success, our comfort level and excellent track record of its use over 100,000 times with only two cases of wire perforations. Once I get more comfortable with the Runthrough, we may start using it more and more. The real difference I felt in using the Runthrough wire was its ability to steer 1:1 and the fact that it gave great support for the delivery of stents and balloons in difficult cases.

Can you provide more detail about the types of cases in which you may consider using the Runthrough?
Vein grafts (particularly the vein graft to circumflex branches) and native diagonal branches, because these vessels make an angle after their origin (going up and then turning down in course). As a result, in these situations, you often require extra support. The second situation where I might consider use of the Runthrough is the tortuous circumflex. In my opinion, these are ideal lesions at this time for the Runthrough NS wire.

Have you noticed any time or cost savings from use of the Runthrough?
Yes. Frequently, in these situations like I mentioned above, we use double-wire (buddy wire) technique. Yet the Runthrough wire permits you to do it all with just one wire. It’s helpful that you don’t need the frequently-used buddy wire techniques in these lesions. Using just one wire means the overall time required will be slightly less, and more importantly, we simply would not need the second wire to give us support. It may also translate into cost savings.

What do you think about the design of the wire?
I think the platinum coil tip really keeps the shape very well. Many times the wire tip bends, which is common with many of the non-hydrophilic guide wires, and with hydrophilic wires, the problem is that the tip becomes straight very quickly. But we have seen that with the Runthrough NS, the tip shape is consistently maintained, which is an added advantage for this wire. It was a pleasant surprise.

Do you have any advice for other labs that may be interested in using this wire?
You always worry about the distal wire tips going into small branches and causing wire perforation, especially the hydrophilic guide wires, but the Runthrough is constructed from a special titanium alloy and the chances it will cause perforation are significantly low. We have actually used close to 120 Runthrough wires at this time, and we have not encountered any perforations. This may be an additional advantage of Runthrough wire in these difficult, challenging cases. With other hydrophilic wires, you always worry about having a wire perforation. The Runthrough has a hydrophilic polymer coating. The wire itself is composed of a platinum coil and a nitinol coil. If we find that the Runthrough wire has very low incidence of perforation (like the BMW), it will be a huge advantage in the field of guidewires. However, I can only make that statement after using Runthrough wire in 500–600 cases. With the use of hydrophilic wires in difficult situations you may have to move stent/balloons back and forth, and at times advance the guide catheters, which may result in inadvertent passage of the guidewire into small vessels and can cause coronary perforation. If use of Runthrough wire minimizes coronary perforation, then we really have a “star” wire in our interventional armamentarium: one which will provide good support, keeps the tip with a 1:1 torque, and potentially minimizes coronary perforation. You can’t ask better than that for any guide wire. Runthrough comes in various different shapes and sizes, along with different tip strengths, but right now, Mount Sinai cath lab has only approved Runthrough NS wire. I think eventually we will have other stiffness like the floppy and intermediate Runthrough, but so far, the Runthrough NS is working out very well.

NULL