Guidewire general techniques

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The ability to cross an atherosclerotic lesion with a coronary guidewire depends upon both the performance characteristics of the giudewire and the skill of the operating physician. This chapter discusses the technique of crossing an atherosclerotic lesion with a coronary guidewire.

Workhorse Guidewire

It is a good general practice to use the same coronary guidewire for the majority of cases. In doing so, the operator becomes very familiar with the behavior characteristics of the wire, and becomes very sensitive to any changes in the behavior of the wire. In general, a flexible wire with a floppy tip that does not have a hydrophilic coating is a good choice as a workhorse guidewire. 90% of lesions should be able to be crossed with this workhorse guidewire.

Preparing the Guidewire

• For the majority of lesions, create a curve at the tip of the guidewire which is roughly the length of the diameter of the vessel proximal to the lesion.
• If you are attempting to cross a total occlusion the tip of the guidewire should be left straighter or with a minimal bend.

Strategies If the Guidewire Fails to Cross the Lesion

• Adjust the guide so that it is more coaxial with the lumen of the artery
• Use a balloon, transit, ultrafuse or twin pass catheter to direct the wire in a more favorable direction
• Modify the bend at the tip of the wire. In tortuous segments, a more proximal secondary bend approximating shape the artery may be required
• Change the wire

SAFETY TIPS

1. Get used to a few wires to suit most situations 2. Always use the least traumatic wire for the lesion, >90% lesions could be crossed with standard “work horse” wires 3. Until familiar and comfortable, do not rush in to wires which are mote likely to perforate. 4. Avoid bending or buckling the wire 5. Never push a wire, let it find its “track” with 6. A ventricular premature beat could be a suggestion that the wire is off track, withdraw the wire immediately and redirect it. 7. Check every fluro and cine loop for evidence for perforation, embolization and dissection. If the picture quality is poor, then do not hesitate to increase the frame count/radiation to improve it. 8. If there is a suspicion of a perforation, then an emergent Echo should be performed on the table. ( link complications – perforation)