The Runthrough NS Guidewire: Lessons after 2,000 uses
We last spoke with Dr. Sharma in March 2008, after he had used the Runthrough wire approximately 120 times (available at https://cathlabdigest.com/article/8531). He commented: “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. 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.”
Now we meet 6 months later, after Dr. Sharma has used the wire 2,000 times.
Dr. Sharma, how have an additional 1,880 uses of the Runthrough wire since we last spoke affected your thoughts on its capabilities?
The Runthrough has become my workhorse wire as of around May, which is phenomenal. Moving the wire, rotating the wire — it just goes without any resistance and without any problem. Most importantly, we have had zero incidence of wire perforation with this wire. The Balance Middleweight wire ([BMW], Abbott Vascular, Redwood City, CA) has been used 200,000 times at Mount Sinai and we have had one perforation. We are now at about 2,000 uses with the Runthrough wire, with no perforation. It is providing support, very little movement and retention of the tip. Mount Sinai cath lab has a very extensive database which allows tracking of the number of lesions, number of vessels, guide wires, stents, and so on, by criteria such as the per-patient number. We recently performed an analysis of my cases only, looking at wire use in the last 6 months of 2007 (every wire use per case) versus the past 3 months (April-June 2008). At this time, the database has been updated only until June 2008, as it takes time for our analyst to input all the data. Every month, I do approximately 110 interventions. We found that over the two time periods, volume remained the same, the rotablation use, for example, remained the same, but my wire use on average was 2.7 per case for the last 6 months of 2007, and for the 3 months of 2008, it was at 2.1, a significant difference in total wire use. Of the many instances in which we knew a tortuous case would have required a buddy wire, we are now able to use a single Runthrough wire instead. The Runthrough wire behaves like a combination of the best of the BMW wire and best of the Fielder wire, the two wires we used to rely upon most heavily. In the past, for angulations and tortuousity, I used to go with the Runthrough, and for straightforward lesions, the BMW, but now I use the Runthrough in the majority of my procedures. What about the financial impact of the decreased wire usage? My wire use per PCI case decreased from 2.7 in the last half of 2007 to 2.1 in April-June of 2008, a difference of 0.6. This is an additional cost savings per patient simply through the use of a single wire instead of adding the additional wire required by the buddy technique. At Mount Sinai, we use approximately 10,000 wires per year, each at a cost of about $90. If we translate this data into an annual lower average wire use, it may result in a savings of about $200,000 per year, which certainly we can use for other programs. Actually, as I noted, the most important thing is still the Runthrough’s clean record of no perforations. In angulated areas, with use of the Fielder (Abbott Vascular, Redwood City, CA) and Whisper (Abbott), we had about 0.2 to 0.3 rate of wire perforation, which means 1 in 300 or 1 in 400 cases. The Runthrough wire has a hydrophobic tip, and there has been no case of perforation. I’m sure it will happen, but so far it has been a very safe wire.
What about factoring in procedural time savings because of the lack of buddy wire use?
Overall, the time it takes to do the procedure does decrease because you are not putting in a buddy wire. Actually, we will also be calculating this data, once we do a little more detailed analysis.
What else have you learned from your experience?
We have found three scenarios in which the Runthrough is not as effective as other wires. In general, if you need to go through the stent struts or through the stent, the Runthrough gives more resistance compared to hydrophilic wires like the Fielder and Whisper. However, it’s important to note that these two wires are considered specialty wires in comparison to Runthrough, which is now becoming a workhorse wire. The first scenario we found is that of “stent jail.” Let’s say you have placed a stent in the left anterior descending artery (LAD) and now the diagonal is originating from the stented segment. We have had difficulty using the Runthrough in these cases. Therefore, if a diagonal branch is coming up from a stented segment, I would not go with the Runthrough wire. If I want to go through the diagonal, I will put in a Fielder wire. If you put a stent in the mid-LAD 6 months ago, and now the patient comes back with disease in the ostium of the diagonal, which is originating in the stented segment in the LAD — in this stent jail situation, the Runthrough wire gives the operator a great deal of difficulty. However, the Fielder wire will go through without a problem, particularly if the angle is more than 90 degrees. The second scenario is if the patient has had multiple stents in the past and now you want to advance another stent through a proximally placed stent. Here, a Runthrough wire is difficult to advance and, if placed on the Runthrough, the stent also gave us difficulty in advancing through a previously placed stent. For example, stents have been placed in the proximal and mid-LAD, but now you need to go to the distal LAD. We found that with the Runthrough wire, we sometimes have difficulty going, but say the wire went through. Now you want to slide the stent through on the Runthrough wire. We found a great deal of resistance resulted. Essentially, a good hydrophilic coating is needed, like that of the Fielder and Whisper, so that the stent will be able to advance. The third scenario is in extremely angulated side branches. The Runthrough does not make the curve and prolapses (meaning to go up and go down), and the Fielder and Whisper will need to be used. I should note that the chronic total occlusion is a situation we have not tried with the Runthrough, as CTOs require a separate, stiff wire. Regardless, even while keeping these three scenarios in mind, for almost 90% of cases, my first choice is still the Runthrough. In the past, I had 55-75% BMW use and 20-25% Fielder use. The Runthrough remains at 90%, because for extreme angulations of the side branches, I will use the Fielder wire. The problem with the Fielder is that the tip can go into a small branch and cause a perforation, because it is very hydrophilic. Second, many times it goes through the branch, but does not give you any support and now you are struggling, trying to advance the stent and creating a problem. Maybe the wire goes distally and you have a little wire perforation. We have found that these issues are eliminated with use of the Runthrough wire.
Where is your lab overall in terms of adopting the Runthrough wire?
As mentioned, I have adopted Runthrough as my workhorse wire and increasingly more and more interventionalists are changing to Runthrough wire as their primary wire.
Can you share more about your interventional fellows program? What type of learning curve do they exhibit with the Runthrough?
The cath lab at Mount Sinai has seven interventional fellows. We are at a pace of 5000+ interventions annually, making us the number one high-volume center in the country. Total procedures are at about 15,000. Seven fellows graduated in June and Mount Sinai started seven new fellows in July. For them, using the Runthrough is simple. They can go through the tortuous, angulated areas without any problem. In the past, we used to tell fellows what curve to make, to advance slowly and so on, but now the wire advances without any problem. During our live case symposium in June, attendees saw very clearly how fellows were able to use the Runthrough in various tortuous, angulated segments, and with very rapid advancement and easy delivery of the stents. Many of our attendings tell me I should not let the fellows use the Runthrough wire, because there is not much teaching in the wire techniques as a result. To me, that’s part of advancement! What we used to struggle with back in the 1990’s, we don’t struggle with today, because balloons, wires and stents have become much more simple and easy. So I resist, because from my point of view, this is a good thing — as long as the wire is safe. We have used 2,000 wires now, with no perforations, which speaks well for the Runthrough. I can say it is a very safe wire, it is very easy to handle, it gives 1:1 torque and provides good support in the majority of cases.
Can you tell us more about the June live case symposium at Mount Sinai?
Each year, we do a June interventional live symposium, attended by between 400-450 people. 2008 marked the 11th year. We do about 18-20 live interventions with national and international faculty. Of course, there are also short lectures on various topics, but the greatest focus is on points of technique. The website is cccsymposium.org.
Any advice for those who may be considering trying the Runthrough?
Just use the wire and you will fall in love with it, because of the ease of use, support and 1:1 torque. It will certainly reduce wire-crossing time in your tough cases. Any last thoughts? I think it’s very simple and easy. The Runthrough is probably the best wire we’ve had in a long, long time.
Dr. Sharma can be contacted at Samin.Sharma@mountsinai.org
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