10/23/2025
PCI wire maneuvering tips; most needed skills in one article 👌
In coronary percutaneous coronary intervention (PCI), the "best" wire maneuvering depends on the complexity of the lesion, vessel anatomy, and operator preference. Effective techniques include standard antegrade wiring for simpler cases and more advanced strategies, such as parallel wiring, anchoring, or retrograde access, for complex lesions like chronic total occlusions (CTOs). A microcatheter is often used to enhance wire support and control.
Foundational techniques
Before any advanced maneuvering, proper technique and equipment are essential.
1- Wire selection: Choosing the right guidewire for the job is crucial. Workhorse wires offer a balance of steering and support for routine cases. For complex lesions, specialized wires are used: polymer-jacketed for tracking through microchannels and stiffer wires for pe*******on.
2- Tip shaping: The tip of the wire is carefully shaped with a 40–60° bend to aid in steering and to navigate the coronary tree.
3- Two-handed control: Many operators use a "both hands maneuver" to achieve precise control. One hand is used for gentle forward and backward movement (advancement and retraction), while the other handles controlled rotation (torque).
Techniques for complex lesions
Antegrade wire escalation (AWE):
AWE is the primary strategy for most CTOs and involves systematically escalating the wire's stiffness and pe*******on power if initial attempts fail.
1- Use a microcatheter: A microcatheter or over-the-wire balloon is advanced to the start of the occlusion. This device is critical for providing support, facilitating wire exchanges, and increasing the wire's pe*******on force.
2- Wire advancement: The operator uses gentle probing, rotation (drilling), and small, controlled movements (sliding) to find the path through the occlusion.
3- Stepwise escalation: If a soft, polymer-jacketed wire fails to cross, the operator may escalate to a stiffer, higher tip-load wire to pe*****te the fibrous cap. Once across, the stiff wire is exchanged for a softer workhorse wire to reduce the risk of perforation.
Parallel wire technique;
If a guidewire enters a subintimal space (the space between the vessel's layers) and cannot re-enter the true lumen, the parallel wire technique can be used.
1- Place a second wire: The initial wire is left in its position to mark the false lumen.
2- Advance a second wire: A second guidewire is advanced in parallel to the first, often with a dual-lumen microcatheter, to find the correct intraplaque path and navigate into the distal true lumen.
Antegrade dissection and reentry (ADR):
For complex CTOs where antegrade wiring fails, ADR uses a controlled subintimal dissection to bypass the blockage.
1- Knuckle wiring: A soft, polymer-jacketed wire is pushed until it forms a loop ("knuckle") at its tip, which is then advanced safely through the subintimal space. The blunt tip minimizes the risk of perforation.
2- CrossBoss and Stingray: The blunt-tipped CrossBoss catheter is used to create a controlled dissection in the subintimal space. The Stingray balloon is then inflated, and the Stingray wire is used to target and re-enter the true lumen beyond the occlusion.
Retrograde approach:
This strategy involves accessing the coronary artery via collateral vessels from another, non-occluded artery, and crossing the CTO from the distal end.
1- Collateral wiring: A guidewire is carefully navigated through collateral channels, typically septal collaterals, which are relatively safe.
2- CART/Reverse CART: This technique uses a retrograde and an antegrade wire to meet within the CTO. A balloon is inflated on one of the wires to connect the two dissection planes, allowing one of the wires to enter the true lumen and cross the lesion.
3- Wire externalization: A retrograde guidewire is advanced into the antegrade guide catheter and then externalized (pulled out of the body) to provide a long, stable rail for delivering balloons and stents.
Support and stabilization techniques:
1- Anchoring: A balloon or wire is placed in a side branch and inflated to provide extra support for delivering balloons or stents across a difficult lesion in the main vessel.
2- Guide catheter extension: A short catheter is extended deeper into the coronary artery to increase support and improve device deliverability.
3- Buddy wire: A second wire is advanced alongside the main wire to straighten a tortuous vessel, acting as a "rail" to help deliver devices.
Key principles for successful maneuvering:
1- Constant visualization: Operators use fluoroscopy from multiple angles, along with techniques like contralateral injection (dye injection from another vessel), to constantly monitor the wire's position.
2- Minimize force: Excessive force can lead to vessel perforation or dissection. If resistance is met, the operator should stop, assess the situation, and change the wire or technique.
3- Know your equipment: Each guidewire has unique properties. Experienced operators are intimately familiar with a small set of wires and their characteristics to know when to escalate or de-escalate
