**2.4 Choosing the appropriate guide wire**

There are large number of guide wires from different companies with different characteristics. Operator should be comfortable and familiar with design, characteristics, advantages, and disadvantages of at least workhorse wires and special wires especially high risk and CTO operators.

**Manufacturer Tip style Commercial name Tip**

Hydrophilic polymer, straight (nontapered)

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

Abbott BALANCE

(But the coil is coated with hydrophilic coating), straight (nontapered)

> polymer, tapered

coated, straight nontapered,

Abbott Whisper LS

Asahi Gladius 3 Terumo Crosswire NT 7.7

Asahi Hydrophobic tip

Asahi Hydrophilic

Asahi Hydrophilic

MIDDLEWEIGHT UNIVERSAL II

> Fielder XT Fielder XT-A Fielder XT-R

Asahi Sion Black 0.8 Mostly used for retrograde

Abbott Pilot 50 1.5 Stronger tip stiffness with

Abbott Pilot 150/200 2.7/4.1 Same as above with stiffer tip

PT Graphic Intermediate

PT2 Moderate support

Whisper MS Whisper ES

Boston Scientific

Boston Scientific

Boston Scientific

Boston Scientific

Boston Scientific

Boston Scientific

**223**

**stiffness (gf)**

Samurai 0.5 Workhorse wire. Longer

Marvel 0.9 Workhorse wire. Longer

ProWater 0.8 Good Workhorse wire with good

0.8 1.0 0.6 1.2

0.8 1.0 1.2

Choice PT Floppy 2.1 Same as above

1.7

2.9

Fighters 1.2 Same as above

Fielder FC 0.8 Can be used as a workhorse wire,

**Clinical tips**

radiopaque segment 4 cm, longer coil 20 cm, which provides more support for tortuous vessels and makes it a good buddy wire

radiopaque segment (3 cm), more slippery than other work hose wires

torque control and support. Has transition point to the stiff part 10 cm to distal tip that operator would feel challenge advancing the wire distally and can cause Wire artifact if it was at a bend. Longer coil (20 cm)

More used in CTO PCI for antegrade crossing and Knuckle technique, retrograde crossing. Fielder XT-R is used for wiring retrograde collaterals

> used more for retrograde approaches in CTO

> > approaches in CTO

Slippery and can wire very small vessels and cause perforation if operator has limited experience

hydrophilic coating that can be used to cross difficult branches but carries higher risk of dissection and that's why it can be used for CTO dissection and reentry techniques

0.7 Hi Torque workhorse wire


#### **Table 13.**

*Steerable, angled, dual lumen micro-catheters.*

Every wire has unique characteristics: the easiest way to remember the details of each wire is dividing them into groups with shared characteristics (**Table 14**).

There are three basic components of guide wires: central core (Stainless steel or Nitinol) and form the first 145 cm (or 140 cm) of guide wires, the distal 40 cm (or 35 cm) which has thinner extension part of the central core covered by polymer sleeve or coil-spring (platinum, tungsten, and stainless steel) and finally the tip which is usually covered by lubricious coating that define the wire as hydrophobic or hydrophilic. The tip is usually radiopaque and varies in length (20 mm–25 cm).

Last few decades have introduced nitinol to wires' design instead of stainless steel. This advancement has shown significant improvement in wires' design. Nitinol is a unique element that allows wires' tip to be more flexible, kink resistance, durable (retain the shape), and reshapable, all of which allow wires to be used several times to cross/wire different lesions and vessels. A very practical and timesaving tool especially in complex, bifurcation, and multivessel interventions.

Guide wire comes in two lengths. Long wires of 300 cm are used to perform exchanges, using micro-catheters, using over the wire balloons, CTO retrograde approaches (and externalization), or while using adjunct therapy like atherectomy. Regular length guide wires of 180 cm are of the workhorse wire length and used with rapid exchange balloons and stents. Few extension wires (Doc wire, Add Wire, Cynch) are available and can be attached to all guide wires when needed.

The goals of guide wires are to cross the target lesion safely without causing any damage to the vessel or alternating of the plaque in addition to providing good support to deliver other equipment (balloons and stents).

The operator's choice of guide wire is dependent mainly on two factors: lesions/ vessel related factors and wire characteristics.

Wire characteristics: shaft characteristics are mainly related to the support and stiffness they provide. Most important characteristics are related to guide wires' tip:


### *Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*


Every wire has unique characteristics: the easiest way to remember the details of

Last few decades have introduced nitinol to wires' design instead of stainless steel. This advancement has shown significant improvement in wires' design. Nitinol is a unique element that allows wires' tip to be more flexible, kink resistance, durable (retain the shape), and reshapable, all of which allow wires to be used several times to cross/wire different lesions and vessels. A very practical and timesaving tool especially in complex, bifurcation, and multivessel interventions. Guide wire comes in two lengths. Long wires of 300 cm are used to perform exchanges, using micro-catheters, using over the wire balloons, CTO retrograde approaches (and externalization), or while using adjunct therapy like atherectomy. Regular length guide wires of 180 cm are of the workhorse wire length and used with rapid exchange balloons and stents. Few extension wires (Doc wire, Add Wire,

Cynch) are available and can be attached to all guide wires when needed.

support to deliver other equipment (balloons and stents).

lesion while increasing the risk of vessel injury.

vessel related factors and wire characteristics.

damage to the vessel or alternating of the plaque in addition to providing good

The goals of guide wires are to cross the target lesion safely without causing any

The operator's choice of guide wire is dependent mainly on two factors: lesions/

Wire characteristics: shaft characteristics are mainly related to the support and stiffness they provide. Most important characteristics are related to guide

Wire tip's strength, shape, and coating: tip can be straight or tapered, have polymer coating or not, have coil support or not, hydrophilic, or hydrophobic. Tapered, polymer coating, coiled, and hydrophilic tips can cross difficult

Strength of the tip: it is how many grams of power is required to bend the tip when applied against the surface of the vessel wire. Multiple wires have a

each wire is dividing them into groups with shared characteristics (**Table 14**). There are three basic components of guide wires: central core (Stainless steel or Nitinol) and form the first 145 cm (or 140 cm) of guide wires, the distal 40 cm (or 35 cm) which has thinner extension part of the central core covered by polymer sleeve or coil-spring (platinum, tungsten, and stainless steel) and finally the tip which is usually covered by lubricious coating that define the wire as hydrophobic or hydrophilic. The tip is usually radiopaque and varies in length

**Length Distal shaft outer**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

140 cm 1.9 distal tip and 3Fr

**diameter (French)**

crossing profile

NinjaSwift Steerable micro catheter to

**Notes**

straight, 45, 90, 120°

help change the angle

help change the angle

2.1 Preformed angled catheter;

2.2 Steerable micro catheter to

(20 mm–25 cm).

**Manufacturer Catheter**

Vascular solutions

**Table 13.**

**name**

Twin Pass Twin Pass Torque

*Steerable, angled, dual lumen micro-catheters.*

SuperCross 130 cm,

Venture 145 cm (rapid

150 cm

exchange) 140 cm (over the wire)

wires' tip:

**222**


number that determine the strength of the tip. The highest the number the

**stiffness (gf)**

5.1, 8.0

8.3, 9.1

8.6, 12

9.1

11.8, 13.

RG3 Only for CTO retrograde

**Clinical tips**

Steer-ability, tip control, tracking, support (push-ability), lubricity: optimal wire has best steer-ability, tip control, tracking and support to cross a lesion or

branch vessel jailed by stent without vessel damage. Ability to provide accurate transmit of torque to the tip of the wire and direct it to where operator needed to be is one of the most important characteristics for any wire.

Always start with a workhorse wire and escalate the strength as needed

Avoid using polymer coated wire at the beginning. Polymer coated wires become stiffer in a warm environment, and pre-shaped ones have no

Advance wire slowly and freely. Assure tip of the wire is free by performing

Find the best safest lumen or micro-channel to cross the lesion using multiple orthogonal views and direct the tip to it while rotating and advancing to cross the lesion. This becomes very important while crossing an occluded vessel (STEMIs) or CTOs to avoid disturbing plaque or wiring sub-intimal space and

Never cross a lesion after the tip bends (Knuckled wire). Pull to straighten the tip and rotate to find the micro-channel. Advancing the wire after bending can cross to sub-intimal space and causes dissection (it is a technique for CTO

stronger the tip.

*Coronaries guide wires 0.014.*

Asahi Externalization

Boston Scientific

solutions

**Table 14.**

**225**

Tips for guide wire handling:

secondary curve.

(Prowater, BMW, Runthrough, etc.).

continuous spinning and advancing slowly.

**Manufacturer Tip style Commercial name Tip**

(philic and phobic)

and phobic)

Confianza Pro 9, 12 (0.009″) Hydrophobic

Hydrophobic

Hydrophobic

wires Asahi Grand Slam 0.7

Mailman

interventions Vascular

R350

Abbott Soft, nontapered Iron Man 1 Extra support wire, good buddy

Medtronic Persuader 3, 6

Medtronic ProVia 3, 6 (philic

polymer, hydrophobic

Medtronic Persuader 9

Medtronic ProVia 9, 12

wires (most common used ones)

Asahi Tapered, no

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

cause thrombosis or dissection/perforation.


#### **Table 14.**

**Manufacturer Tip style Commercial name Tip**

Cordis Shinobi 7.0 Cordis Shinobi Plus 6.8

> Hydrophilic, Straight

Asahi SION blue (less

M-coating hydrophilic/ hydrophobic coating

Abbott Tapered Cross it 100XT

polymer, hydrophilic

Abbot Progress 140 T

Medtronic Persuader 9

Medtronic ProVia 9, 12

polymer

Abbott Progress 40, 80,

Abbott Ultimate 3 3

Asahi Straight tip, no

Asahi Astato 20 (0.008″) 20

Asahi No polymer,

Terumo Tapered,

Asahi Tapered, no

Boston Scientific

Boston Scientific

**224**

**stiffness (gf)**

> 1.o 0.7

1.7

1.7 3.5 4.5

9.3 12

12. 13.3

9.1

11.8, 13.5

10, 14

3.9, 4.4, 8.8

5.5, 9.7, 13.9

course is known MiracleBros 12 13

Asahi SION 0.7 Most common wire used for

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

hydrophilic)

Runthrough NS Extra Floppy (Tip 0.008) RUNTHROUGH NS HYPERCOAT

(0.010″)

Gaia 1st (0.010″) Gaia 2nd (0.011″) Gaia 3rd (0.012″)

tortuosity Asahi Confianza Pro 9, 12 (0.009″)

> (0.0105″) Progress 200 T (0.009″)

> > (0.011″)

(0.009″)

Hornet 10, 14 (0.00″)

MiracleBros, 3, 4.5, 6

120

Suoh 03 0.3 Very low profile wire so best to

Samurai RC 1.2 More support than Samurai with

**Clinical tips**

wire EPICARDIAL collaterals and minimize risk of perforation

wiring collaterals

longer coil 24 cm and much higher tip stiffness

"M-coat" technology hydrophilic coating over the distal 24.8 cm of the distal tip enables smooth tractability in the tortuous anatomy while the silicone tip on the distal 2 mm Recently became one of the workhorse wires given its favorable crossing profile for complex PCI and ability to use same wire for different lesions and reshaping the tip

High stiffness tip so used for crossing CTO in a vessel with known course or retrograde known course without significant

High tip stiffness, Antegrade crossing for CTO when vessel

0.5 Good Workhorse wire

*Coronaries guide wires 0.014.*

number that determine the strength of the tip. The highest the number the stronger the tip.

Steer-ability, tip control, tracking, support (push-ability), lubricity: optimal wire has best steer-ability, tip control, tracking and support to cross a lesion or branch vessel jailed by stent without vessel damage. Ability to provide accurate transmit of torque to the tip of the wire and direct it to where operator needed to be is one of the most important characteristics for any wire.

Tips for guide wire handling:


interventions using specific wires and the goal is to cross to sub-intimal space and re-cross to true lumen). One exception is presence of large burden of thrombus and unclear trajectory of the vessel. In such case, operator might use the knuckle technique to minimize the risk of vessel injury as knuckled workhorse wire can pass easily through thrombus and allow safely the true lumen and trajectory of the vessel. Still, this technique is better performed by experienced operator.

closer to the tip. A secondary curve is the bend distal to the tip. Basic rule for shaping is making primary curve mates most angulated vessel bend and secondary curve matches the vessel size. A simple primary curve is enough in most cases. A primary 120 angle curve is usually referred to as a CTO curve because it provides a good strength to cross the lesion and mainly used in CTO lesions. When operator is working on a distal lesion with tortuous vessel a secondary curve is required most of the time to reach the distal lesion. In left system interventions, a lot of the times the LAD and/or LCX comes out with very acute angle. Such case would require mainly a secondary curve to cross the first angle of takeoff unless further tortuosity distally is present then another curve is required. The more acute the curve and especially secondary curve, the more likely that the wire would be entering the branch vessels. That is because a secondary curve is more likely to be larger than the width of the vessel which makes the wire easier to reach branches. For the same reason, if the vessel is straight, a simple short primary curve is sufficient to reach a distal

lesion without difficulty wiring all branches across the vessel.

wire. Sometimes this catheter can be too short to trap the wire.

To avoid withdrawing the wire and losing wire position:

the exchange then it is deflated and pulled out.

techniques:

*Coronary Artery Intervention Techniques DOI: http://dx.doi.org/10.5772/intechopen.93458*

wire position is critical.

advanced in a usual manner.

diameter peripheral balloons can be used.

**2.5 Balloons and angioplasty**

**227**

Extension wires are very helpful when a long wire is needed in cases that require the use of over the wire balloon, micro catheter, or atherectomy. To perform catheter exchanges (micro catheter or OTW balloon) over a regular length wire while assuring minimal or no movement of the wire, there are few

A trapper catheter which is special catheter with a balloon designed to trap the

Advancing an extra balloon inside the GC close to the tip without getting out of the guide catheter then inflating the balloon to trap the wire while performing

A 3 cc syringe filled of heparinized saline is attached to the catheter hub and continuous slow injection is performed after assuring no air in the system. That generates enough energy to prevent the wire from being withdrawn while pulling the catheter are pulled out of guide. This technique is least successful and requires a lot of experience and luck. It is not a trusted

technique, so it is not encouraged to be used in critical scenarios where losing

To avoid wire migration distally while advancing the catheter, a 10 cc syringe is attached to the catheter hub then a slow negative pressure is applied while the it is advanced till the wire is seen coming out of the hub inside the syringe. At this point the syringe is disconnected, the wire is railed, and the catheter is

Multiple balloons with different designs from multiple companies are available. Main important characteristics for balloons are: balloon diameter, length, compliance, rupture pressure, tip designs, crossing profile, shaft diameter and length. Standard diameter for coronary interventions starts from 1.2 mm and goes up. However, there are commercially available smaller balloons: nano-balloon 0.85 and 1 mm balloons (Sapphire Pro, Ikazuchi Zero, Ryurel). If necessary, even large

Selection of Balloons: after wiring the target vessel and lesion, balloon can be advanced and inflated to perform angioplasty. The goal of pre-dilatation of lesion is to prepare lesion for stenting and assess whether the lesion/plaque would response to balloon and stenting afterwards would have a good results or further plaque


interventions using specific wires and the goal is to cross to sub-intimal space and re-cross to true lumen). One exception is presence of large burden of thrombus and unclear trajectory of the vessel. In such case, operator might use the knuckle technique to minimize the risk of vessel injury as knuckled workhorse wire can pass easily through thrombus and allow safely the true lumen and trajectory of the vessel. Still, this technique is better performed by

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

Pull the branch wire before performing optimization of stent apposition when a

To avoid perforation: keep a wire in a main large vessel (not small branch) and be aware of the distal tip of the wire at all times especially while performing multiple over the wire exchanges where the wire can travel distally and cause perforations. These kinds of distal perforation can be missed easily unless operator pays a good attention to angiograms. Also, the distal perforation causes slow bleeding that can take hours to manifest as tamponade. Thus, early

Develop a tactile feed-back for wires to avoid wiring small branch vessel or

Wire effect or pseudo stenosis (Accordion's effect): occurs more in tortuous vessels and wires with strong shaft that can straighten the vessel at the tortuous segments and cause pseudo-stenosis (lesions) and even dissections. Examining baseline images can help distinguish this effect in addition to repeat angiogram after pulling the stiff segment of the wire out of the tortuous segment of the vessel. This way, operator can be assured that it is a wire effect and at the same time in safe position to re-advance the wire if the repeat angiogram revealed true damage (dissection or plaque shifting) that requires

In cases that require more guide wires support, operators can use buddy wire technique by using additional wire with good support or (if the support wire can be advanced) exchanging the workhorse wire for a strong support wire

For cases where wiring a jailed vessel through stent struts, operator would choose a wire with good tip control, tracking and lubricity to direct the wire toward the vessel lumen jailed by stent. Strength here is not necessary and wires with high strength should be avoided as it carries higher risk of perforation or crossing under stent struts and dissect the branch vessel that supposed to be wired. However, some strength might be required in case of significant lesion in the branch vessel. That is why the operator should always plan the techniques for bifurcation stenting that requires rewiring based on the easiest vessel to rewire in addition to other factors will discuss later. To avoid under stent wiring, operator can use the main vessel wire and use it to wire the branch vessel. As long as operator does not withdraw the wire beyond the stent proximal edge level, operator can be comfortable that the wire is not

Strength is important in CTO or heavy calcified/organized thrombus lesions. Wires with higher strength tip should be used when the vessel track/trajectory is easy to see. Having a balloon or micro catheter close to the tip to increase support can increase the strength of the tip by 10 times and even more

Shaping the tip of the wire: also an important step to get to the lesion especially in tortuous vessels and to cross the target lesion. Operators have different ways to approach the best shape for a specific lesion. Primary curve is the bend

wiring under stent (between stent and vessel's wall).

detection and prevention are very important.

using over the wire balloon or micro-catheter.

Any wire can cause perforation especially distal end perforation.

experienced operator.

further intervention.

under stent.

**226**

depending on the wire.

stent is jailing a branch wire.

closer to the tip. A secondary curve is the bend distal to the tip. Basic rule for shaping is making primary curve mates most angulated vessel bend and secondary curve matches the vessel size. A simple primary curve is enough in most cases. A primary 120 angle curve is usually referred to as a CTO curve because it provides a good strength to cross the lesion and mainly used in CTO lesions. When operator is working on a distal lesion with tortuous vessel a secondary curve is required most of the time to reach the distal lesion. In left system interventions, a lot of the times the LAD and/or LCX comes out with very acute angle. Such case would require mainly a secondary curve to cross the first angle of takeoff unless further tortuosity distally is present then another curve is required. The more acute the curve and especially secondary curve, the more likely that the wire would be entering the branch vessels. That is because a secondary curve is more likely to be larger than the width of the vessel which makes the wire easier to reach branches. For the same reason, if the vessel is straight, a simple short primary curve is sufficient to reach a distal lesion without difficulty wiring all branches across the vessel.

