This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It begins by outlining the history of angioplasty and guidewire development. It then covers the purpose, components, classifications, and appropriate uses of guidewires. The main components include the core, tip, coils, covers, and coatings. Guidewires are classified based on flexibility, device support, and clinical usage. Complications like vessel perforation, pseudolesions, and entrapment are also discussed. Proper guidewire manipulation and strategies for difficult lesions are outlined to maximize safety and efficacy.

1. CORONARY GUIDEWIRES,CHOICE
AND APPROPRIATE USE IN PCI

3. •GRUNTZIG First performed Angioplasty in 1974
•1977 – First coronary angioplasty
•Polyvinyl Chloride balloon catheter with short guidewire
attached to its tip

4. •1982 – Simpson reported
First experience with over
the wire balloon system
•It had an independently
movable guidewire within
the balloon dilation
catheter

5. CONTENTS
• PURPOSE OF GUIDEWIRE
• COMPONENTS OF A GUIDE WIRE
• CLASSIFICATION
• WIRES FOR DIFFERENT OCCASIONS
• GUIDEWIRE MANIPULATION
• COMPLICATIONS

6. • To track through the vessel
• To access the lesion
• To cross the lesion atraumatically
• To provide support for interventional devices

7. Guidewire main characteristics
 Torque control Is an ability to apply rotational force at a
proximal end of a guidewire and have that force
transmitted efficiently to achieve proper control at the
distal end
 Trackability Is an ability of a wire to follow the wire tip
around curves and bends without buckling or kinking, to
navigate anatomy of vasculature
 Steerability Is an ability of a guidewire tip to be delivered to
the desired position in a vessel
 Flexibility Is an ability to bend with direct pressure

8.  Prolapse tendency Tendency of the body of a wire
not to follow the tip around bends
 Radiopacity/visibility Is an ability to visualise a
guidewire or guidewire tip under fluoroscopy.
 Tactile feedback Is tactile sensation on a proximal
end of a guide wire that physician has that tells him
what the distal end of the guidewire is doing
 Crossing Is an ability of a guidewire to cross lesion
with little or no resistance
 Support Is an ability of a guidewire to support a
passage of another device or system over it

9. STRUCTURE
 CORE-Material
Diameter
Core taper
 TIP
 COILS, COVERS & COATINGS

10. Core
• Inner part of the guidewire
• Extends through the shaft of the wire from the
proximal to the distal part
• Stiffest part of the wire that gives stability and
steerability

11. Core Material
Core material affects the flexibility, support, steering
and trackability
• Stainless steel
– superior torque characteristics, can deliver more push,
provides good shapeability and excellent support
– more susceptible to kinking and is less flexible
• Nitinol
– pliable but supportive, less torquability than SS
– generally considered kink resistant & have a tendency to
return to their original shape, making them potentially
less susceptible to deformation during prolonged use

12. Core Diameter
• Influences the performance of the wire
• Larger diameter improves support and allows 1:1
torque response
• Smaller diameter enhances the flexibility
Core taper
• Variable length
• Continuous/segmented
• Short taper and smaller number of wide spaces
increases support and transmission of push force
• Longer tapers and larger numbers of segmented
tapering increases flexibility

14. Tip
• Tapers distally to a variable extent
– 2-piece core- distal part of core does not reach
distal tip of wire→ shaping ribbon, extends to
distal tip
– 1-piece core- tapered core reaches distal tip.
• 2-piece→ easy shaping & durable shape
memory
• 1-piece →better force transmission to tip &
greater “tactile response” for operator

16. Coils, Covers & Coating
Keeps the diameter at .014 inch
• Coils
– Stainless steel
– Outer coil Design – Coils placed over tapered core
and tip of the wire
– Tip coil Design – Tip alone is covered with coils
– Flexibility, support, steering, tracking, visibility &
tactile feedback
– Radio opaque platinum coils

17. Coils

18. Radio-opaque tip
• Visibility of the wire tip is provided by radiopaque
platinum coils that are usually placed at the distal
tip 2 to 3 cm in length, but maybe much longer.
• Many workhorse Wires – 3 cm distal radio-
opaque tip

19. COVERS

20. • Coating
– Distal half
– Affects lubricity and tracking
– Creates tactile feel
– Reduces friction
– Facilitates movement of wire within the vessel and
deliverability of intervention equipment

21. Non-Coated / Hydrophobic wires
Pros
• More controllable (and therefore less likely to dissect)
• Provide better tactile feel
Cons
• Poor trackability
• Wire tip becomes stiffer, torque response increases,
but less tip resistance is transmitted to the operator,
making it easier to enter a false channel.

22. HYDROPHOBIC
• Hydrophobic coatings are silicone based
coatings which repel water and are applied on
the working length of the wire, with the
exception of the distal tip. They require no
activation by liquids to create a "wax-like"
surface and to achieve the desired effect
— to reduce friction and increase trackability
of the wire. Silicone coating has higher
friction, more stable feel inside the vessel.

23. Hydrophilic
• Applied over the entire working length of wire
including tip coils
• Attracts water - needs lubrication
• Thin, non slippery, solid when dry→ becomes a gel
when wet
– ↓friction
– ↑trackability
– ↓Thrombogenic
↓tactile feel- ↑risk of perforation
Tendency to stick to angioplasty cath
• Useful in negotiating tortuous lesions and in
“finding microchannels” in total occlusions

25. Shapeability and shaping memory
• Shapeability - allows to modify its distal tip
conformation
• Shaping memory - ability of tip to return back
to its basal conformation after having been
exposed to deformation & stress
– Both do not necessarily go in parallel
– SS core wires -easier to shape (↑memory- nitinol
core)
– 2-piece core + shaping ribbon - easier to shape &
↑memory

26. HOW TO CLASSIFY CORONARY
GUIDE WIRES?

27. CLASSIFICATION
• NO UNIFORM CLASSIFICATION
• BUT SOME CATEGORISATION

29. Classification
Based on Tip Flexibility
• Floppy – Eg:- Hi torque balance middle weight, Hi
torque balance,Choice floppy
• Intermediate – Eg:- Hi torque intermediate, Choice
intermediate
• Standard – Shinobi (Boston Scientific)
Based on Device support
• Light – Eg:- Hi torque balance
• Moderate – Eg:- Hi torque balance middle Weight
• Extra support – Eg:- Hi torque whisper,Choice EXTRA

30. “Support”
• Indicator of the core strength
• More stronger the core – more support

31. Floppy
ES – Extra-Support
Grand-Slam
Iron-man

33. Based on coating
• Hydrophilic : Eg:- CholCETM PT Floppy
• Hydrophobic : Eg:- Asahi soft
Depending on tip load
• Floppy, Balanced & Extra support
• Tip load - force needed to bend a wire when
exerted on a straight guide wire tip, at 1 cm
from the tip
– Floppy - <0.5g
– Balanced – 0.5-0.9g
– Extra support - >0.9g

35. BASED ON CLINICAL SCENARIO

38. Commonly Used Workhorse
Guidewires
• ATW/ATW Marker
• Stabilizer
• BMW / BMW Universal
• Zinger
• Cougar XT
• Asahi Light / Medium
• Asahi Standard
• Asahi Prowater Flex
• Choice Floppy
• Luge
• IQ
• Forte Floppy
• Runthrough NS
• Galeo

39. Balance Middleweight Universal wire
(Abbott Vascular/Guidant, Santa Clara, CA)
• Quite steerable - tip is suitable for bending in a “J”
configuration for distal advancement into the distal vessel
bed with minimal trauma while still maintaining some
torque
• shape retention relatively poor -any J configuration tends to
become magnified over time → consequent loss in
steerability
• moderately torquable- progression - minimal friction (light
hydrophilic coating) - Dye injection may also be helpful to
propagate distal advancement
• suitable for rapid, uncomplicated interventions
• low risk to cause dissections/distal perforations
• support - low to moderate

40. CHOICE FLOPPY

42. ALL TRACK WIRE(ATW) (CORDIS)
• General purpose, moderate support
guidewire with floppy tip and integrated
Flex-Joint ™ bond which contributes to
flexibility and precise steering and
atraumatic vessel tracking.
• The central core is coated with PTFE
providing
non-thrombogenic and durable platform for
smooth delivery of multiple devices.
• The distal 3 cm radio-opaque tip is however,
uncoated providing for good tactile response.
• For measurement of lesion length, four
markers span 31 mm in 10 mm increments
proximal to the radio-opaque tip.
• The only limitation of this wire is relatively
poor tip support and lack of tip durability
(multi-lesion/multi-vessel interventions may
not be possible with a single wire)

43. ASAHI PROWATER FLEX
• Prowater™ (Asahi Intec Co.) is the
next generation Asahi wire which has
a newly designed stainless steel core
shaft and a hydrophilic coating over
the spring coil (combination of
stainless steel and platinum/iridium
alloy) which offers higher support
plus an improved torque
performance as compared to
previous generation Asahi soft
guidewire.
• It is a highly maneuverable wire but
at the same time it is very floppy.
• Thus it is possible to approach a
variety of lesions including in
tortuous lesions without causing any
dissections, pseudo dissections and
other complications with the wire.

44. SELECTION OF GUIDEWIRES FOR
SPECIAL LESIONS

45. The selection of a guidewire
• Essential component
• INFLUENCED BY
• vessel anatomy
• the lesion morphology
• the devices to be used
• operator's experience and preference.

46. LEFT MAIN PCI
• The choice of a guidewire is not of critical
importance.
• Wire selection usually includes spring tip
guidewire designed for frontline lesions, for
example, ChoICE™ Floppy (Boston Scientific),
Hi-Torque Balance Middleweight (Abbott
Vascular)
• FOR LEFT MAIN OR RCA OSTIAL PCI AN
EXTRASUPPORT WIRE IS PREFERED

47. BIFURCATION PCI
• In the presence of difficulties accessing the
side branch some hydrophilic wires such as
the ChoICE™ PT Floppy (Boston Scientific), PT
Graphix™ (Boston Scientific) or Asahi Fielder
(Abbott Vascular) may become useful.

48. • These wires have higher risk to perforate the
distal vessel if allowed to migrate into small
side branches or too distally. Therefore it is
important to monitor the distal position of the
wire tip. These wires also should not to be
jailed because of the risk of wire rupture
during pullback.

49. DISSECTIONS
• ChOICE Floppy
• Asahi Soft .
• The parallel wire technique can be
recommended if a dissection plane is entered
with the first wire
• Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi
H, Obara C. The latest wire technique for chronic
total occlusion. Ital Heart J 2005;6:489-93..

50. CALCIFIED LESIONS
• ChoICE Floppy (Boston Scientific).
• If it fails to cross the lesion, the next step is to
choose floppy hydrophilic wire such as the
ChoICE PT Floppy (Boston Scientific) or Asahi
Fielder (Abbott Vascular)

51. TORTUOUS ANATOMY
• Very floppy wire with support for device
delivery could be used
• BMW
• FIELDER FC
• WHISPER ES
• WIGGLE WIRE

54. CTO WIRES

56. CLASSIFICATION OF CTO WIRES

59. CTO guide wire techniques

60. Lesion specific CTO approaches
SLIDING
 Micro-channels present
 CTO’s < 6 months
 ISR total occlusions
 STAR technique
Hydrophilic wires
Fielder,Crosswir
eNT, HT Pilot,
Whisper, Choice
PT

61. Lesion specific CTO approaches
DRILLING
(controlled)
“Workhorse technique”
Most CTOs with discrete
entry point after initial attempt
with soft (intermediate wires)
Stiff , hydrophobic
non-tapered wires
MiracleBros (3 g, 4.5 g and
6 g), Persuader (3 g and 6 g)
and Cross-IT XT
(100/200/300)

62. Lesion specific CTO approaches
Penetration
• Blunt entry point
• Heavily calcific or resistant lesions
• Alternative to “drilling” as the
“work horse technique” after initial soft wire failure
Super stiff
tapered wires
Conquest Pro (9 g,
12 g), Cross-IT XT
400, MiracleBros 12

63. GUIDEWIRES FOR RETROGRADE
TECHNIQUES
– Fielder/FielderFC
– X -treme
– Whisper
– ChoICE PT2
– Runthrough / Runthrough Hypercoat

64. COMMONLY USED CTO WIRES

67. Fielder™ / Fielder FC™ (Asahi Intec Co.)
• Special guidewire - distal coil coated with
polymer sleeve & further coated with a
hydrophilic coating
• Provides advanced slip performance &
trackability for highly stenosed lesion & tortuous
vessels
• Very good torque performance
• Combines both slide and torque performance
• Primary wire used in the retrograde technique of
recanalization of CTO

70. Whisper
• Durasteel™ Core-to-tip designed to improve
steering, durable shape retention and tactile
feedback
• Full Polymer cover with Hydrophilic coating
intended for deliverability and smooth lesion
access
• Responsease™ “transitionless” core grind
designed to provide improved tracking and better
torque response
• Tip coils designed to provide softer, shapeable tip
and also improve tactile feedback

71. CONQUEST SERIES

72. SUMMARY OF WIRES

74. Guidewire Manipulations
• Two step process
• Shaping the wire tip
– It minimizes the amount of force applied to the
wire
– For steering into the vessel
– For visualization of torquing effort

75. Shaping the Wire Tip

76. Steering of the wire
• Small alternating rotations to left and right
• Excessive rotations should be avoided to
prevent wire tip fracture

77. Optimum guide wire positioning
• Should be placed as distally as possible in the
target vessel
• Allows extra support when crossing with
balloon/stent catheters
• ↓ chance of the wire becoming displaced
backwards across the lesion and necessitating
re-crossing
Avoid vessel perforation when positioning
wires with hydrophilic coatings very distally

78. Strategies if Guidewire fails to cross
• Make the guide more coaxial with the lumen
of the artery
• Use a balloon to direct the wire
• Modify the bend at the tip of the wire
• Change the wire

79. Complications
• Vessel perforations
– Uncommon <1%
– Risk factors
• Hydrophilic wires, core to tip
• Chronic total occlusions
– Diagnosis
• Angiographic diagnosis
• Small extraluminal extravasation of blush in the distribution
of target vessel
• Emergency echo to r/o pericardial effusion and tamponade
– Prognosis
• Extent of extravasation into pericardium

80. –Classification
• Type I – Extraluminal crater without extravasation
• Type II – Containing pericardial or myocardial
blushing
• Type III - having≥ 1 mm diameter with contrast
streaming and cavity spilling
–Management
• Reversal of anticoagulations
• Prolonged balloon inflation
• PTFE covered stent
• Coil embolization
• Use of gel foams

81. Pseudolesions/Concertina effect
• Stenosis that appears in any artery after the coronary
guidewire is placed in the artery
• Appears in tortuous vessels that have been straightened
out by the guidewire

82. Diagnosis
• Will disappear if the wire is withdrawn
• Replacement of a stiff wire with a flexible
floppy wire eliminates pseudolesion
Complications
• In some cases cause hemodynamic
compromise and ischemia

84. Guidewire Entrapment
Factors
• Presence of calcified vessels.
• Repeated use of wire for multiple interventions
• Repeated attempts at crossing the same lesion
multiple times with the same wire
• Two wires may become entrapped when the
“Buddy wire” technique is used
• Crossing stent struts

85. Management
• Advance a small profile balloon or a small caliber
catheter (transit catheter) to the attachment site
and pull back gently
• When a second or “buddy wire” gets trapped
between a stent and the vessel wall gentle
traction can be used
• Surgery

86. Guidewire fracture and Embolization
• Risk factors are calcified lesion, bifurcation
stenting and prolonged procedures
• Management
– Surgery
– Snaring the Embolized wire fragment
• The Amplatz Gooseneck Microsnare
• The EnSnare Triple Loop Device
• The X Pro Micro Elite Snare
• The Alligator Retrieval Device
– Push and paste

87. THANK YOU